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

Emotion regulation strategies and perceived stress during pregnancy in expectant mothers and fathers

BACKGROUND

Stress during pregnancy can increase physical and mental health risks in parents and offspring. Emotion regulation (ER) may protect against prenatal stress; however, ER is understudied in expectant parents, particularly expectant fathers. This study aimed to evaluate associations between ER strategies (reappraisal, suppression, ratio of suppression-to-reappraisal) and perceived stress among expectant parents, and also test whether expectant mothers and fathers differed in ER strategy use and perceived stress levels.

METHODS

N = 83 expectant parents (62.7% mothers) in the third trimester completed measures assessing perceived stress,reappraisal, and suppression. ANCOVA, hierarchical regression, and multilevel models were used to evaluate associations between ER strategies and perceived stress, and test for sex differences.

RESULTS

Controlling for age and education, lower reappraisal and higher suppression were associated with higher perceived stress; in addition, higher suppression-to-reappraisal ratios were associated with greater perceived stress. Mothers and fathers did not differ in perceived stress, reappraisal, or suppression; however, suppression-to-reappraisal ratios significantly differed.

CONCLUSION

Increasing ER skills such as reappraisal while reducing suppression may be beneficial for decreasing stress in expectant parents. Expectant fathers report similar levels of perceived stress to mothers and would benefit from prenatal mental health screening and intervention.

Postpartum Depression: A Clinical Review of Impact and Current Treatment Solutions

Depression during the first year postpartum (postpartum depression) impacts millions of women and their families worldwide. In this narrative review, we provide a summary of postpartum depression, examining the etiology and consequences, pharmacological and psychological treatments, and potential mechanisms of change and current barriers to care. Psychological treatments are effective and preferred by many perinatal patients over medications, but they often remain inaccessible. Key potential mechanisms underlying their effectiveness include treatment variables (e.g., dosage and therapeutic alliance) and patient behaviors (e.g., activation and avoidance and emotional regulation). Among pharmacological treatments, the selective serotonin reuptake inhibitor (SSRI) sertraline is generally the first-line antidepressant medication recommended to women in the postpartum period due to its minimal passage into breastmilk and the corresponding decades of safety data. Importantly, most antidepressant drugs are considered compatible with breastfeeding. Neurosteroids are emerging as an effective treatment for postpartum depression, although currently this treatment is not widely available. Barriers to widespread access to treatment include those that are systematic (e.g., lack of specialist providers), provider-driven (e.g., lack of flexibility in treatment delivery), and patient-driven (e.g., stigma and lack of time for treatment engagement). We propose virtual care, task-sharing to non-specialist treatment providers, and collaborative care models as potential solutions to enhance the reach and scalability of effective treatments to address the growing burden of postpartum depression worldwide and its negative impact on families and society.

Project ECHO in Psychiatric Workforce Development: the Example of a Perinatal Mental Health ECHO

OBJECTIVE

Perinatal mental health and substance use disorders (PMHSUD) often go unrecognized and untreated. This study examined the use of the Project ECHO model to teach obstetric, primary care, and mental health clinicians about screening, diagnosis, and treatment of PMHSUD.

METHODS

Participants in 3 years of the University of Washington's Moms' Access Project (MAP) ECHO program (2019-2022) completed pre- and post-program surveys. Nine participants in year 1 completed qualitative interviews. Dedoose was used for qualitative analysis of interviews.

RESULTS

Of 136 participants, 62.5% (15/24) completed both pre- and post-surveys in year 1, 56% (28/50) in year 2, and 32.2% (20/62) in year 3. Most respondents agreed or strongly agreed that they were glad to have participated (96.8%; 60/62) and that they had used information learned in the program in treating a patient (95.1%; 58/61). In all years, respondents endorsed increased confidence regarding learning objectives of the program. Qualitative interviews following year 1 yielded themes of hierarchy of competence, motivation versus results of participation, connection, and politics of change: position and practice type.

CONCLUSIONS

Findings supported the feasibility, acceptability, and self-reported effectiveness of the ECHO model for workforce development in PMHSUD.

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.

Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.

Digital screening for mental health in pregnancy and postpartum: A systematic review

PURPOSE

This systematic review aimed to determine if digital screening for mental health in pregnancy and postpartum is acceptable, feasible and more effective than standard care (paper-and pen-based screening or no screening). The second aim was to identify barriers and enablers to implementing digital screening in pregnancy and postpartum.

METHOD

OVID MEDLINE, PsycINFO, SCOPUS, CINAHL, Embase, Web of Science, Joanna Briggs Database and All EMB reviews incorporating Cochrane Database of Systematic Reviews (OVID) were systematically searched for articles that evaluated digital screening for mental health in pregnancy and postpartum between 2000 and 2021. Qualitative articles were deductively mapped to the Theoretical Domains Framework (TDF).

RESULTS

A total of 34 articles were included in the analysis, including qualitative, quantitative and mixed-methods studies. Digital screening was deemed acceptable, feasible and effective. TDF domains for common barriers included environmental context and resources, skills, social/professional role and identity and beliefs about consequences. TDF domains for common enablers included knowledge, social influences, emotion and behavioural regulation.

CONCLUSION

When planning to implement digital screening, consideration should be made to have adequate training, education and manageable workload for healthcare professionals (HCP's). Organisational resources and support are important, as well as the choice of the appropriate digital screening assessment and application setting for women. Theory-informed recommendations are provided for both healthcare professionals and women to inform future clinical practice.

Behavioral Health Integration on Inpatient Obstetric Units: Program Development, Strategies for Implementation, and Lessons Learned

Perinatal mood and anxiety disorders and substance use disorders are the primary causes of maternal mortality in the postpartum period and represent major public health concerns. Despite this, these conditions remain undertreated. Behavioral health integration in outpatient obstetric settings is necessary but insufficient to meet the needs of all patients. Inpatient behavioral health integration represents a promising avenue for addressing gaps in care. Results from recent program development indicate that needs assessment, stakeholder backing, collaboration with existing programs, and adaptability are key factors in successful implementation.

Perinatal Mood and Anxiety Disorder and Reproductive Justice: Examining Unmet Needs for Mental Health and Social Services in a National Cohort

Introduction

Perinatal Mood and Anxiety Disorders (PMADs) are the most common complications during the perinatal period. There is limited understanding of the gaps between need and provision of comprehensive health services for childbearing people, especially among racialized populations.

Methods

The Giving Voice to Mothers Study (GVtM; n=2700), led by a multistakeholder, Steering Council, captured experiences of engaging with perinatal services, including access, respectful care, and health systems' responsiveness across the United States. A patient-designed survey included variables to assess relationships between race, care provider type (midwife or doctor), and needs for psychosocial health services. We calculated summary statistics and tested for significant differences across racialized groups, subsequently reporting odds ratios (ORs) for each group.

Results

Among all respondents, 11% (n=274) reported unmet needs for social and mental health services. Indigenous women were three times as likely to have unmet needs for treatment for depression (OR [95% confidence interval, CI]: 3.1 [1.5-6.5]) or mental health counseling (OR [95% CI]: 2.8 [1.5-5.4]), followed by Black women (OR [95% CI]: 1.8 [1.2-2.8] and 2.4 [1.7-3.4]). Odds of postpartum screening for PMAD were significantly lower for Latina women (OR [95% CI]=0.6 [0.4-0.8]). Those with midwife providers were significantly more likely to report screening for anxiety or depression (OR [95% CI]=1.81 [1.45-2.23]) than those with physician providers.

Discussion

We found significant unmet need for mental health screening and treatment in the United States. Our results confirm racial disparities in referrals to social services and highlight differences across provider types. We discuss barriers to the integration of assessments and interventions for PMAD into routine perinatal services.

Implications

We propose incentivizing reimbursement schema for screening and treatment programs; for community-based organizations that provide mental health and social services; and for culture-centered midwife-led perinatal and birth centers. Addressing these gaps is essential to reproductive justice.

The cost-effectiveness of zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States

AIMS

The objective of this research is to evaluate the cost-effectiveness of zuranolone, the first oral treatment indicated for postpartum depression (PPD) in adults approved by the United States Food and Drug Administration.

METHODS

Zuranolone and selective serotonin reuptake inhibitor (SSRI) trial-based efficacy was derived from an indirect treatment comparison. Long-term efficacy outcomes were based on a large longitudinal cohort study. Maternal health utility values were derived from trial-based, short-form 6-D responses. Other inputs were derived from literature and economic data from the US Bureau of Labor Statistics. We estimated costs (2023 US dollars) and quality-adjusted life-years (QALYs) for patients with PPD treated with zuranolone (14-day dosing) or SSRIs (chronic dosing). The indirect costs and QALYs of the children and partners were also estimated.

RESULTS

The incremental cost-effectiveness ratio for zuranolone versus SSRIs was $94,741 per QALY gained over an 11-year time horizon. Maternal total direct medical costs averaged $84,318 in the zuranolone arm, compared to $86,365 in the SSRI arm. Zuranolone-treated adults averaged 6.178 QALYs compared to 6.116 QALYs for the SSRI arm. Costs and utilities for the child and partner were also included in the base case. Drug and administration costs for zuranolone averaged $15,902, compared to $30 for SSRIs over the studied time horizon. Results were sensitive to the model time horizon.

LIMITATIONS

As head-to-head trials were not available to permit direct comparison, efficacy inputs were derived from an indirect treatment comparison which can be confounded by cross-trial differences. The data used are reflective of a general PPD population rather than marginalized individuals who may be at a greater risk for adverse PPD outcomes. The model likely excludes unmeasured effects for patient, child, and partner.

CONCLUSIONS

This economic model's results suggest that zuranolone is a more cost-effective therapy compared to SSRIs for treating adults with PPD.

Improving maternal mental health: assessing the extent of screening and training about peripartum depression

OBJECTIVE

Peripartum depression (PPD) is a common mental health complication of pregnancy and increases risk for maternal mortality and poorer outcomes for children. Despite its importance, screening rates vary across organizations and care team members. The goal of the current study was to explore the perspectives from care team members in both behavioral health and acute care settings about how they screen and refer pregnant and post pregnant women for PPD, what training around PPD is currently offered by their organization, and if they could benefit from additional PPD training.

METHODS

Data were collected from an online self-report survey of care team members from behavioral health and acute care settings in the US. Questions focused on (1) when/if the care teams had a screening protocol for PPD, (2) beliefs about the efficacy of their organization's PPD screening, identification, and referral process, and (3) if their organization currently offered or needed training around the topic of PPD.

RESULTS

A total of 794 care team members in behavioral health and acute care responded to the survey between December 2021 and May 2022. Nearly, all (96.7%) reported having a specific protocol for screening for PPD when they know a patient is pregnant; however, only 69.6% of respondents routinely screen regardless of symptoms being reported by the patient. While 93.3% of the sample believed their organization does a good job screening for and identifying PPD, gaps in the referral processes were described, especially in acute settings. 95.3% of the sample reported their organization currently gives training in screening, identifying, or treating PPD or in the process for establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients; however, 96.5% also reported their organization would benefit from additional training in one or more of these areas.

CONCLUSION

High rates of self-reported PPD screening and training indicate that care team members in both behavioral health and acute care are aware of the importance of maternal mental health issues. However, other research indicates that high rates of screening may not lead to improved outcomes, and there are still high rates of maternal suicide and suicidal ideation in the US. It is possible that high self-reported screening rates may indicate a false sense of security such that care team members feel the issue is addressed while problems remain. Alternatively, many respondents felt their organizations would benefit from further training, perhaps indicating an awareness of this gap. Care team members in behavioral health and acute care settings should increase collaboration to ensure high rates of screening lead to improved maternal mental health care.

A systematic review on automated clinical depression diagnosis

Assessing mental health disorders and determining treatment can be difficult for a number of reasons, including access to healthcare providers. Assessments and treatments may not be continuous and can be limited by the unpredictable nature of psychiatric symptoms. Machine-learning models using data collected in a clinical setting can improve diagnosis and treatment. Studies have used speech, text, and facial expression analysis to identify depression. Still, more research is needed to address challenges such as the need for multimodality machine-learning models for clinical use. We conducted a review of studies from the past decade that utilized speech, text, and facial expression analysis to detect depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. We provide information on the number of participants, techniques used to assess clinical outcomes, speech-eliciting tasks, machine-learning algorithms, metrics, and other important discoveries for each study. A total of 544 studies were examined, 264 of which satisfied the inclusion criteria. A database has been created containing the query results and a summary of how different features are used to detect depression. While machine learning shows its potential to enhance mental health disorder evaluations, some obstacles must be overcome, especially the requirement for more transparent machine-learning models for clinical purposes. Considering the variety of datasets, feature extraction techniques, and metrics used in this field, guidelines have been provided to collect data and train machine-learning models to guarantee reproducibility and generalizability across different contexts.

Equitable reach: Patient and professional recommendations for interventions to prevent perinatal depression and anxiety

OBJECTIVE

Perinatal depression and anxiety are the most common complications in the perinatal period and disproportionately affect those experiencing economic marginalization. Fewer than 15% of individuals at risk for perinatal depression are referred for preventative counseling. The goal of this study was to elicit patient and perinatal care professionals' perspectives on how to increase the reach of interventions to prevent perinatal depression and anxiety among economically marginalized individuals.

METHODS

We conducted qualitative interviews with perinatal individuals with lived experience of perinatal depression and/or anxiety who were experiencing economic marginalization (n = 12) and perinatal care professionals and paraprofessionals (e.g., obstetrician/gynecologists, midwives, doulas; n = 12) serving this population. Three study team members engaged a "a coding consensus, co-occurrence, and comparison," approach to code interviews.

RESULTS

Perinatal individuals and professionals identified prevention intervention delivery approaches and content to facilitate equitable reach for individuals who are economically marginalized. Factors influential included availability of mental health counselors, facilitation of prevention interventions by a trusted professional, digital health options, and options for mental health intervention delivery approaches. Content that was perceived as increasing equitable intervention reach included emphasizing stigma reduction, using cultural humility and inclusive materials, and content personalization.

CONCLUSIONS

Leveraging varied options for mental health intervention delivery approaches and content could reach perinatal individuals experiencing economic marginalization and address resource considerations associated with preventative interventions.

Understanding Perinatal Depression Care Gaps by Examining Care Access and Barriers in Perinatal Individuals With and Without Psychiatric History

Background: Depression affects one in seven perinatal individuals and remains underdiagnosed and undertreated. Individuals with a psychiatric history are at an even greater risk of perinatal depression, but it is unclear how their experiences with the depression care pathway may differ from individuals without a psychiatric history. Methods: We conducted a secondary analysis evaluating care access and barriers to care in perinatal individuals who screened positive for depression using the Edinburgh Postnatal Depression Scale (N = 280). Data were analyzed from the PRogram in Support of Moms (PRISM) study, a cluster randomized controlled trial of two interventions for perinatal depression. Results: Individuals with no prepregnancy psychiatric history (N = 113), compared with those with a history (N = 167), were less likely to be screened for perinatal depression, and less likely to be offered a therapy referral, although equally likely to attend if referred. When examining how these differences affected outcomes, those without a psychiatric history had 46% lower odds of attending therapy (95% confidence interval [CI]: 0.19-1.55), 79% lower odds of taking medication (95% CI: 0.08-0.54), and 80% lower odds of receiving any depression care (95% CI: 0.08-0.47). Barriers were similar across groups, except for concerns regarding available treatments and beliefs about self-resolution of symptoms, which were more prevalent in individuals without a psychiatric history. Conclusions: Perinatal individuals without a prepregnancy psychiatric history were less likely to be screened, referred, and treated for depression. Differences in screening and referrals resulted in missed opportunities for care, reinforcing the urgent need for universal mental health screening and psychoeducation during the perinatal period. Clinical Trial Registration No.: NCT02935504.

Views of healthcare professionals and service users regarding anti-, peri- and post-natal depression in Oman

WHAT IS KNOWN ON THE SUBJECT?: Anti-, peri- and post-natal depression negatively affect the relationship between mothers and their children. At least half of cases of anti-, peri- and post-natal depression were missed and underdiagnosed by healthcare professionals (HCPs) including doctors, nurses and midwives. Previous qualitative studies considered women's experiences relating to anti-, peri- and post-natal depression separately from studies looking at the views of HCPs. There is a lack of research in Middle Eastern countries, despite the high prevalence of anti-, peri- and post-natal depression. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This is the first qualitative study investigating the experiences of both HCPs and service users regarding anti-, peri- and post-natal depression from the Middle East perspective, particularly in Oman. This study revealed that anti-, peri- and post-natal depression has been neglected in primary healthcare systems in Oman. The study explored many barriers and facilitators which have been identified by both HCPs and patients in identifying and managing anti-, peri- and post-natal depression in the primary healthcare system. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses, midwives and doctors should develop an empathic screening procedure that allows for the discussion of mental health concerns and help-seeking behaviours with their patients. Training nurses and midwives in motivational interviewing, routinely screening mothers with any depressive symptoms, as well as providing public education programmes to increase mental health awareness, resources and access to a variety of mental healthcare alternatives, could be successful in recognizing and managing anti-, peri- and post-natal depression.

ABSTRACT

INTRODUCTION: Anti-, peri- and post-natal depression is known to affect the relationship between infants and their mothers adversely. Previous studies have identified barriers and facilitators, reported by women and HCPs, related to the identification and management of anti-, peri- and post-natal depression. However, these studies considered the experiences of women separately from those of the healthcare professionals, even though their experiences of anti-, peri- and post-natal depression are interconnected. Additionally, there is a lack of research among people living in the Middle East, including Oman, which has one of the highest rates of anti-, peri- and post-natal depression globally.

AIM

This study aimed to explore the views and experiences of HCPs and service users relating to anti-, peri- and post-natal depression from the Middle East perspective.

METHOD

A qualitative descriptive study using semi-structured interviews was conducted. This study took place at the Family Medicine and Community Clinic at the University Hospital and three selected primary healthcare centres in Muscat, between May 2020 and February 2021. Purposive sampling was used: 15 HCPs with 2-20 years of clinical experience in anti-, peri- and post-natal primary care and 13 pregnant patients plus 2 post-birth patients were interviewed. Audio-recordings were transcribed verbatim, and the anonymized transcripts were then entered into the qualitative data management software, NVIVO 12.

RESULTS

A thematic approach was used to analyse the data. Four themes were identified in the data, namely: (1) making sense of anti-, peri- and post-natal depression; (2) how to deal with anti-, peri- and post-natal depression; (3) barriers to addressing anti-, peri- and post-natal depression in primary anti-, peri- and post-natal care settings and (4) bridging the gap: facilitators in detecting and managing anti-, peri- and post-natal depression.

CONCLUSIONS

Improving the identification and management of anti-, peri- and post-natal depression in primary healthcare systems will require a whole-system approach with interventions at the patient, practice and comprehensive primary care team levels.

IMPLICATIONS FOR PRACTICE

The findings suggest implications for improving the identification and management of anti-, peri- and post-natal depression including an increased emphasis on mental health by enhancing the routine screening of mothers during the anti-, peri- and post-natal period, clearer referral systems, improving resources, providing training with regard to mental health and improving communication skills.

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

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

The end of Roe v. Wade: implications for Women's mental health and care

The Supreme Court decision in Dobbs v. Jackson in June 2022 reversed precedent which had previously protected abortion prior to fetal viability as a universal right within the United States. This decision almost immediately led to abortion restrictions across 25 states. The resulting lack of access to abortion care for millions of pregnant people will have profound physical and mental health consequences, the full effects of which will not be realized for years to come. Approximately 1 in 5 women access abortions in the U.S. each year. These women are diverse and represent all American groups. The Supreme court decision, however, will affect populations that have and continue to be marginalized the most. Forcing pregnant individuals to carry unwanted pregnancies worsens health outcomes and mortality risk for both the perinatal individual and the offspring. The US has one of the highest maternal mortality rates and this rate is projected to increase with abortion bans. Abortion policies also interfere with appropriate medical care of pregnant people leading to less safe pregnancies for all. Beyond the physical morbidity, the psychological sequelae of carrying a forced pregnancy to term will lead to an even greater burden of maternal mental illness, exacerbating the already existing maternal mental health crisis. This perspective piece reviews the current evidence of abortion denial on women's mental health and care. Based on the current evidence, we discuss the clinical, educational, societal, research, and policy implications of the Dobbs v. Jackson Supreme Court decision.

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care.

METHODS

This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother-infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap.

RESULTS

Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = -4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93-4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03-5.04). Participants reported improvements in mother-infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone.

CONCLUSIONS

One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother-infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Evaluating an Online Intervention to Improve Provider Management of Prenatal Depression: A Randomized Controlled Trial

INTRODUCTION

Prenatal depression is associated with numerous deleterious maternal and child health outcomes. Providers play a significant role in managing (i.e., identifying and treating or referring to care for) prenatal depression. We conducted a randomized controlled trial to test the effects of a brief online training on self-reported provider management practices related to prenatal depression.

METHODS

Providers (i.e., physicians, nurses, mental health specialists, and public health educators) were randomized into intervention (i.e., online training) or waitlist control arms. The online training covered guidelines and evidence-based practices related to managing prenatal depression. Changes in providers' knowledge, attitudes, and self-reported practices were assessed by the Management of Maternal Depression Inventory at baseline (T1), 6 weeks after baseline (T2), and 12 weeks after baseline (T3).

RESULTS

A total of 108 providers from Colorado and Virginia participated in the trial. Over the three time periods, repeated measures analysis of variance revealed Time × Group relative improvements for the intervention group with respect to satisfaction with working with mental health services, F(1,97) = 10.89, p = .001, partial η² = 0.10, and increased self-reported screening, counseling, and referral for prenatal depression, F(1,97) = 6.25, p = .014, partial η² = 0.06. A similar improving pattern was observed for self-efficacy, F(1,99) = 2.48, p = .13, partial η² = .02.

CONCLUSIONS

Findings from our study suggest a brief online training may enhance the likelihood of providers screening, treating, and/or referring at-risk patients for follow-up care for prenatal depression.

Risk factors associated with postpartum depression in a high-risk maternity clinic: a cross-sectional study

BACKGROUND

The aim of this study was to evaluate obstetric, epidemiological and social factors related to postpartum depression (PPD) and investigate possible risk factors related to this disorder, in puerperal women who had their childbirth and were referred to the High-Risk Outpatient Clinic.

METHODS

A cross-sectional study from August-December/2019 was carried out. One hundred seventy-one puerperal women were analyzed by filling out an epidemiological questionnaire and the Edinburgh Postpartum Depression Scale (EPDS) Form. Scores ≥10 were considered positive. Research on risk factors for postpartum depression was carried out.

RESULTS

29.8% of mothers had a score related with PPD. Breastfeeding without complication is protective against PPD (P=0.002 and χ²=12.533). In contrast, not having a planned pregnancy (P=0.0175, χ²=5.717), having depression at any stage of life (P=0.013, χ²=6.237), depression during pregnancy (P≤0.0001, χ²=46.201) or having a family history of depression (P=0.001, χ²=10.527), are factors associated with the development of PPD. Moreover, just having depression during pregnancy was found to be a significant risk factor for the occurrence of PPD, increasing the risk of developing this pathology by 12 times (OR=12.891).

CONCLUSIONS

Depression during pregnancy is an important risk factor for the development of PPD. This can easily be detected using the Edinburgh Postpartum Depression Scale and treated in a timely manner.

The role of clinician assistants in addressing perinatal depression

BACKGROUND

Upwards of one in seven individuals experience perinatal depression and many individuals cannot access treatment. In response, perinatal depression is increasingly being managed in the obstetric setting. This study aimed to characterize the experiences of clinicians and clinician assistants to inform the extent to which clinician assistants can help address depression in obstetric settings.

METHODS

This cross-sectional analysis used data from an ongoing cluster randomized control trial: The PRogram In Support of Moms (PRISM). Participants included clinicians (physicians, certified nurse midwives, nurse practitioners) and clinician assistants (medical assistants, nursing assistants). Baseline data regarding practices and attitudes of clinicians and clinician assistants toward addressing depression in the obstetric setting were described. Logistic regressions were used to examine the association of clinician time to complete work and depression management.

RESULTS

Clinician assistants experienced significantly fewer time constraints than did clinicians. However, having adequate time to complete work was not significantly associated with increased depression management in clinicians. Clinician assistants reported feeling that addressing depression is an important part of their job, despite variation in doing so.

CONCLUSION

Clinician assistants are interacting with perinatal women extensively and are a vital part of obstetric care workflows. Clinician assistants report that they want to address depression and have time to do so. Thus, clinician assistants may be poised to help address the mental health needs of perinatal individuals.

Screening for PTSD during pregnancy: a missed opportunity

Background

Prenatal posttraumatic stress disorder (PTSD) is often overlooked in obstetric care, despite evidence that untreated PTSD negatively impacts both mother and baby. OB-GYN clinics commonly screen for depression in pregnant patients; however, prenatal PTSD screening is rare. Although the lack of PTSD screening likely leaves a significant portion of pregnant patients with unaddressed mental health needs, the size of this care gap has not been previously investigated.

Methods

This retrospective chart review study included data from 1,402 adult, pregnant patients who completed PTSD (PTSD Checklist-2; PCL) and depression (Edinburgh Postnatal Depression Survey; EPDS) screenings during a routine prenatal care visit. Descriptive statistics identified screening rates for PTSD and depression, and logistic regression analyses identified demographic variables associated with screening outcomes and assessed whether screening results (+ PCL/ + EPDS, + PCL/-EPDS, -PCL/ + EPDS, -PCL/-EPDS) were associated with different provider intervention recommendations.

Results

11.1% of participants screened positive for PTSD alone, 3.8% for depression alone, and 5.4% for both depression and PTSD. Black (OR = 2.24, 95% CI [1.41,3.54]) and Latinx (OR = 1.64, 95% CI [1.01,2.66]) patients were more likely to screen positive for PTSD compared to White patients, while those on public insurance were 1.64 times (95% CI [1.21,2.22]) more likely to screen positive compared to those with private insurance. Patients who screened positive for both depression and PTSD were most likely to receive referrals for behavioral health services (44.6%), followed by -PCL/ + EPDS (32.6%), + PCL/-EPDS (10.5%), and -PCL/-EPDS (3.6%). A similar pattern emerged for psychotropic medication prescriptions.

Conclusions

Over ten percent of pregnant patients in the current study screened positive for PTSD without depression, highlighting a critical mental health need left unaddressed by current obstetric standards of care. Routine PTSD screening during prenatal care alongside strategies aimed at increasing referral resources and access to mental health services are recommended.

A national survey on adaptations by perinatal psychiatry access programs to promote perinatal mental healthcare equity

OBJECTIVE

Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity.

METHODS

One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity.

RESULTS

Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs.

CONCLUSION

Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

Factors affecting the implementation of task-sharing interventions for perinatal depression in low- and middle-income countries: A systematic review and qualitative metasynthesis

Background The vast majority of women with perinatal depression (PND) live in low- and middle-income countries (LMICs). Task sharing is an alternative delivery strategy to implement PND services. However, the exploration of influencing factors for task sharing in PND services is poor. Therefore, this study aimed to identify factors affecting LMICs to implement PND task-sharing interventions from the perspective of stakeholders and weigh their levels of evidence. Methods A comprehensive literature search was carried out through six English and Chinese databases on qualitative data. We used Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT) to appraise included studies, extracted data according to the Consolidated Framework for Implementation Research (CFIR), and assigned levels of confidence in the factors through Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Results 17 studies met the eligibility criteria, factors identified with high levels of evidence were coded to the CFIR constructs, including "Knowledge and Attitudes of Those Served by the Organization", "Available Resources", "Compatibility", "Access to knowledge and information", "Resources of Those Served by the Organization" and "Alignment". Conclusion This metasynthesis highlights task sharing in PND interventions is influenced by multiple factors. We synthesized and developed implementation recommendations for practice. Strategies must be actively developed to enable women and their families to enjoy the benefits of good perinatal mental health.

Racial inequities in the course of treating perinatal mental health challenges: Results from listening to mothers in California

BACKGROUND

Concern with depression during the perinatal period has resulted in multiple states enacting legislation to require universal screening of mothers for postpartum depression. Despite this concern, rates of women receiving mental health counseling during pregnancy and postpartum remain low. This study examines factors, especially inequities in race/ethnicity, associated with receiving perinatal mental health counseling.

METHODS

This study draws on data from the Listening to Mothers in California survey of 2539 women, based on a representative sample of birth certificate files of women who gave birth in 2016. The survey included a series of mental health questions, based on the 4-item Patient Health Questionnaire (PHQ-4), and questions on the receipt of counseling, whether a practitioner asked respondents about their mental health, and whether the respondent was taking medications for anxiety or depression.

RESULTS

We found non-Latina Black women to experience both higher rates of prenatal depressive symptoms and significantly lower use of postpartum counseling services and medications than non-Latina White women. Among women with depressive symptoms, those asked by a practitioner about their mental health status reported a 46% rate of counseling compared with 20% who were not asked, and in a multivariable analysis, those asked were almost six times more likely (aOR 5.96; 95% CI 1.6-21.7) to report counseling.

DISCUSSION

These findings lend evidence to those advocating for state laws requiring universal screening for depressive symptoms to reduce inequities and help address the underuse of counseling services among all women with depressive symptoms, particularly women of color.

Assessment of Canadian perinatal mental health services from the provider perspective: Where can we improve?

PURPOSE

Perinatal mental health disorders are common, and rates have increased during the COVID-19 pandemic. It is unclear where providers may improve perinatal mental health care, particularly in countries lacking national guidelines, such as Canada.

METHODS

A cross-sectional survey of perinatal health providers was conducted to describe the landscape of perinatal mental health knowledge, screening, and treatment practices across Canada. Providers were recruited through listservs, social media, and snowball sampling. Participants completed an online survey that assessed their perinatal mental health training, service provision types, their patient wait times, and treatment barriers, and COVID-19 pandemic-related impacts.

RESULTS

A total of 435 providers completed the survey, including physicians, midwives, psychologists, social workers, nurses, and allied non-mental health professionals. Most (87.0%) did not have workplace mandated screening for perinatal mental illness but a third (66%) use a validated screening tool. Many (42%) providers stated their patients needed to wait more than 2 months for services. More than half (57.3%) reported they did not receive or were unsure if they received specialized training in perinatal mental health. Most (87.0%) indicated there were cultural, linguistic, and financial barriers to accessing services. Over two-thirds (69.0%) reported the COVID-19 pandemic reduced access to services.

CONCLUSION

Survey findings reveal significant gaps in training, screening tool use, and timely and culturally safe treatment of perinatal mental health concerns. There is critical need for coordinated and nationally mandated perinatal mental health services in Canada to improve care for pregnant and postpartum people.

Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review

Mental disorders during pregnancy are common, with long-lasting negative effects on mother and child. Treatment of these women is challenging, because of the high incidence of additional psychosocial problems and barriers on population and healthcare level. Collaborative care, collaboration between mental health and obstetric care professionals, may help to overcome these problems. The aim of this review is to review antenatal mental health interventions and analyse the impact of collaborative care. Two independent reviewers searched for RCT's in PubMed, Embase and PsycINFO. Trials studying the effect of psychological or pharmacological interventions on the mental health of pregnant women with psychiatric symptoms (and psychosocial problems) were eligible for inclusion. Two reviewers independently abstracted data and assessed study quality and risk of bias. Each study was scored on collaborative care criteria: multi-professional approach to patient care, structured management plan, scheduled patient follow-ups and enhanced interprofessional communication. Thirty-five studies were included. Most trials studied the effect of cognitive behavioural therapy and interpersonal psychotherapy on antenatal depression. Almost all interventions met at least one collaborative care criteria. Interventions were mostly provided by multiple professionals, but interprofessional communication rarely took place. Interventions that met more criteria did not more often show a positive effect on maternal mental health. There is lack of research on antenatal psychiatric disorders other than depressive and on long-term treatment outcomes. Collaborative care is partly implemented in most current interventions, but more trials (including interprofessional communication) are needed to be conclusive whether collaborative care is a key component in antenatal mental healthcare.

A Non-Randomized Trial of In-Person Versus Text/Telephone Screening, Brief Intervention and Referral to Treatment for Pregnant and Postpartum Women

Background

Systems of care that improve mental health and substance use disorder Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant and postpartum women are needed.

Aims

The aim of this study is to determine if women receiving prenatal care from January 2020 to April 2021 are more likely to be screened, screen positive, be referred for treatment and attend treatment with technology facilitated SBIRT, compared to women receiving prenatal care and in-person SBIRT January 2017 to December 2019.

Materials & Methods

Technology facilitated SBIRT, designated Listening to Women (LTW), includes text message-based screening, phone-based brief intervention, and referral to treatment by a remote care coordinator. A total of 3535 pregnant and postpartum women were included in the quasi-experimental study and data were collected via text message and Electronic Health Record.

Results

In-person SBIRT was completed by 65.2% (1947/2988) of women while 98.9% (547/553) of women approached agreed to take part in LTW and 71.9% (393/547) completed SBIRT via LTW. After controlling for potentially confounding variables, women enrolled in LTW were significantly more likely to be screened (relative risk [RR]: 1.10, 95% CI 1.03-1.16), screen positive (RR 1.91, 95% CI 1.72-2.10), referred to treatment (RR 1.55, 95% CI 1.43-1.69) and receive treatment (RR 4.95, 95% CI 3.93-6.23), compared to women receiving in-person SBIRT. Black women enrolled in LTW were significantly more likely to screen positive (RR 1.65, 95% CI 1.35-2.01), be referred to treatment (RR 1.54, 95% CI 1.35-1.76) and attend treatment (RR 5.49, 95% CI 3.69-8.17), compared to Black women receiving in-person SBIRT.

Discussion

LTW appears to increase the proportion of pregnant and postpartum women receiving key elements of SBIRT.

Building Obstetric Provider Capacity to Address Perinatal Depression Through Online Training

Background: Perinatal depression is common, underdiagnosed, and undertreated. Obstetric providers often do not receive training in perinatal depression, despite being the frontline providers for perinatal individuals. The objective of this study was to develop and pilot test an online training module to assess feasibility, efficacy, and acceptance in improving obstetric providers' knowledge, skills, and practices regarding perinatal depression. Materials and Methods: We designed, developed, and implemented an online, asynchronous, interactive educational module that trains obstetric providers to: (1) know the prevalence and impact of perinatal depression; (2) use validated tools for depression screening; (3) assess for depression; and (4) start and/or refer for treatment. Formative evaluation with five providers, iterative module and question refinement, and a pilot test with pre- and post-test knowledge and self-efficacy questions were conducted. Results: Sixteen obstetric providers averaged a 32% improvement in their pre- to post-test scores (p < 0.01). The average pretest score was 49% (range 20%-70%), and the average post-test score was 81% (range 70%-95%). Provider beliefs (p = 0.01), self-efficacy (p < 0.01), and confidence (p < 0.01) in treating perinatal depression were also significantly increased between pre- and post-test. Average Likert scores on overall training satisfaction were very high post-training completion (4.44 out of 5, with 5 being most positive). Conclusions: The module was feasible and effective at improving provider knowledge of perinatal depression, self-rated confidence, and self-efficacy. Improving the knowledge and skills of obstetric providers regarding depression is a critical part of any intervention aimed to close gaps in care and help ensure that patients receive optimal treatment.

Results of a Statewide Survey of Obstetric Clinician Depression Practices

Purpose: Perinatal depression affects upwards of one in seven women and is associated with significant negative maternal and child consequences. Despite this, it remains under-detected and under-treated. We sought to identify clinician practices, self-efficacy, and remaining barriers to comprehensively addressing perinatal depression care. Materials and Methods: Surveys were administered to obstetric clinicians in Massachusetts that queried frequency of depression screening and Likert questions about subsequent depression management. Results: Approximately 79.0% of clinicians approached completed the survey. Whereas most clinicians (93.5%) screened for perinatal depression at 6 weeks postpartum, fewer clinicians (66.1%) screened during pregnancy. Most reported they were comfortable providing support to their patients (98.4%), but fewer endorsed being able to treat them on their own (43.0%). Most noted an ability to treat with antidepressants (77.9%); however, fewer endorsed adequate access to nonmedication treatment (45.5%). Conclusions: The majority of surveyed clinicians screen for depression consistent with guidelines. However, efforts are focused on the postpartum period, despite literature citing two-thirds of patients experiencing onset before or during pregnancy. Respondents indicated an ability to treat with medication management, while noting greater challenge with referral. These findings describe the challenges of interdisciplinary coordination as a barrier to comprehensive perinatal mental health care. Clinical Trial Registration Number: NCT02760004.

Optimizing Social-Emotional-Communication Development in Infants of Mothers With Depression: Protocol for a Randomized Controlled Trial of a Mobile Intervention Targeting Depression and Responsive Parenting

BACKGROUND

Postpartum depression interferes with maternal engagement in interventions that are effective in improving infant social-emotional and social-communication outcomes. There is an absence of integrated interventions with demonstrated effectiveness in both reducing maternal depression and promoting parent-mediated practices that optimize infant social-emotional and social-communication competencies. Interventions targeting maternal depression are often separate from parent-mediated interventions. To address the life course needs of depressed mothers and their infants, we need brief, accessible, and integrated interventions that target both maternal depression and specific parent practices shown to improve infant social-emotional and social-communication trajectories.

OBJECTIVE

The aim of this study is to evaluate the efficacy of a mobile internet intervention, Mom and Baby Net, with remote coaching to improve maternal mood and promote parent practices that optimize infant social-emotional and social-communication development.

METHODS

This is a two-arm, randomized controlled intent-to-treat trial. Primary outcomes include maternal depression symptoms and observed parent and infant behaviors. Outcomes are measured via direct observational assessments and standardized questionnaires. The sample is being recruited from the urban core of a large southern city in the United States. Study enrollment was initiated in 2017 and concluded in 2020. Participants are biological mothers with elevated depression symptoms, aged 18 years or older, and who have custody of an infant less than 12 months of age. Exclusion criteria at the time of screening include maternal homelessness or shelter residence, inpatient mental health or substance abuse treatment, or maternal or infant treatment of a major mental or physical illness that would hinder meaningful study participation.

RESULTS

The start date of this grant-funded randomized controlled trial (RCT) was September 1, 2016. Data collection is ongoing. Following the institutional review board (IRB)-approved pilot work, the RCT was approved by the IRB on November 17, 2017. Recruitment was initiated immediately following IRB approval. Between February 15, 2018, and March 11, 2021, we successfully recruited a sample of 184 women and their infants into the RCT. The sample is predominantly African American and socioeconomically disadvantaged.

CONCLUSIONS

Data collection is scheduled to be concluded in March 2022. We anticipate that relative to the attention control condition, which is focused on education around maternal depression and infant developmental milestones with matching technology and coaching structure, mothers in the Mom and Baby Net intervention will experience greater reductions in depression and gains in sensitive and responsive parent practices and that their infants will demonstrate greater gains in social-emotional and social-communication behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03464630; https://clinicaltrials.gov/ct2/show/NCT03464630.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31072.

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

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

Unmet Mental Health Care Needs and Illicit Drug Use During Pregnancy

OBJECTIVES

The prevalence of drug use is at alarmingly high levels in the United States. Of particular concern is prenatal drug use, which exposes the underdeveloped organ systems of the fetus to harsh chemicals. Identifying factors associated with illicit drug use during pregnancy is critical to identify and treat at-risk pregnant women and improve maternal and infant health outcomes. The goal of this study was to examine the association between unmet mental health care needs and substance use during pregnancy.

METHODS

The present cross-sectional study analyzed secondary data from the 2002 to 2014 National Survey on Drug Use and Health (n = 10,516). The main outcome of interest was self-reported illicit drug use in the last 30 days. The independent variable was unmet mental health care needs in the last 12 months.

RESULTS

Overall, 6.4% of the participants reported a history of unmet mental health care needs and 4.5% used a substance during pregnancy. The odds of illicit drug use during pregnancy were higher among women who had an unmet mental health care needs compared to women without a history of unmet mental health care needs, multivariable-adjusted odds ratio (95% CI) 4.06 (3.01 to 5.48; P < 0.001). The observed association between unmet mental health care needs and illicit drug use persisted in subgroup analyses by age, race/ethnicity and education.

CONCLUSION

In a nationally representative cross-sectional sample of pregnant women, having unmet mental health care needs was positively associated with illicit drug use during pregnancy after adjusting for potential confounders.

"We do not know how to screen and provide treatment": a qualitative study of barriers and enablers of implementing perinatal depression health services in Ethiopia

BACKGROUND

Qualitative studies evaluating maternal mental health services are lacking in Ethiopia, and the available evidence targets severe mental illnesses in the general population. We conducted a qualitative study to explore barriers to, enablers of, or opportunities for perinatal depression health services implementations in Ethiopia.

METHODS

We conducted a total of 13 face to face interviews with mental and maternal health service administrators from different levels of the Ethiopian healthcare system. We interviewed in Amharic (a local language), transcribed and translated into English, and imported into NVivo. We analysed the translated interviews inductively using thematic framework analysis.

RESULTS

The study identified: (i) health administrators' low literacy about perinatal depression as individual level barriers; (ii) community low awareness, health-seeking behaviours and cultural norms about perinatal depression as socio-cultural level barriers; (iii) lack of government capacity, readiness, and priority of screening and managing perinatal depression as organisational level barriers; and (iv) lack of mental health policy, strategies, and healthcare systems as structural level barriers of perinatal mental health implementation in Ethiopia. The introduction of the new Mental Health Gap Action Programme (mhGap), health professionals' commitment, and simplicity of screening programs were identified enablers of, or opportunities for, perinatal mental health service implementation.

CONCLUSIONS

This qualitative inquiry identified important barriers and potential opportunities that could be used to address perinatal depression in Ethiopia. Building the capacity of policy makers and planners, strengthening the mental healthcare system and governance should be a priority issue for an effective integration of maternal mental health care with the routine maternal health services in Ethiopia.

Mid-Pregnancy Insomnia and its Association with Perinatal Depressive Symptoms: A Prospective Cohort Study

Objective/Background: Insomnia and depression are disorders that affect many perinatal women and that often are interrelated. The present study aimed to examine concurrent and prospective associations between mid-pregnancy insomnia and depression during mid-pregnancy and 8 weeks postpartum. Furthermore, differences in depression and in the sleep-related characteristics insomnia, chronotype, and sleep efficiency were explored between the two time points (mid-pregnancy versus 8 weeks postpartum), and between primiparous and multiparous participants.Participants/Methods: The study was part of the Norwegian population-based Depression and Anxiety in the Perinatal Period (DAPP) prospective cohort study. Among 539 women that were recruited for participation when receiving a routine ultrasound examination, we analyzed data from hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8. We used the Edinburgh Postnatal Depression Scale to measure depression. The Bergen Insomnia Scale, the reduced Horne-Östberg Morningness-Eveningness Questionnaire, and three questions from the Pittsburgh Sleep Quality Index were used to measure the sleep-related characteristics.Results: Mid-pregnancy insomnia was significantly associated with concurrent depression (p < .001), but not with postpartum depression (p = .288), in a linear mixed model with adjustment for several reproductive and psychosocial variables. Sleep efficiency was reduced from mid-pregnancy to postpartum (from 88% to 77%), and primiparous women reported less efficient sleep than multiparous women after childbirth.Conclusions: The results indicate that mid-pregnancy insomnia may be a marker for concurrent depression but not a predictor of postpartum depression. Future research should examine the extent to which treatment of insomnia from mid-pregnancy on reduces both perinatal insomnia and depression.

Depression Outcomes From a Fully Integrated Obstetric Mental Health Clinic: A 10-Year Examination

BACKGROUND: A fully integrated Obstetric Mental Health Clinic (OBMHC) was established in 2007 in the rural northwest United States to address perinatal depression. AIMS: The purpose of this mixed methods study was to examine depression outcomes in women receiving outpatient psychiatric services between 2007 and 2017 at a fully integrated OBMHC and to explore patient and obstetric team perceptions of OBMHC experiences. METHOD: A retrospective database study was employed; depression was measured at baseline and follow-up visits using the Edinburgh Postnatal Depression Scale. Descriptive statistics, regression models, and trend analysis were employed to determine effectiveness. A subset of patients participated in telephone interviews; the obstetric team was surveyed regarding perceptions of the service. RESULTS: The sample included 192 women (195 pregnancies). Approximately 72% experienced less depression by the first follow-up visit. Patients taking three or more psychiatric medications attended more OBMHC visits. Trend analysis indicated that women with the highest levels of depression had the best response to the intervention. Three qualitative themes emerged: Safe Place, Mental/Emotional Stability, and Integrated Personalized Approach. Obstetric team members (n = 11) perceived the clinic to be helpful and noted improved access to mental health care. CONCLUSION: OBMHCs can be effective when psychiatric nurses are embedded within an outpatient obstetric service. Improved access, timely services, and patient reassurance can lead to an improved pregnancy experience and reduced depressive symptoms. The longevity of this clinic's experience serves as a role model for other centers to replicate this successful integrated model of care.

Brexanolone in Postpartum Depression: Post Hoc Analyses to Help Inform Clinical Decision-Making

Background: Brexanolone (BRX) injection was approved by the United States Food and Drug Administration in 2019 for the treatment of adults with postpartum depression (PPD) based on two Phase 3 clinical trials. Materials and Methods: Data from the three trials were combined. PPD-specific 17-item Hamilton Rating Scale for Depression (HAMD-17) group-level minimal important difference (MID) and patient-level meaningful change (meaningful change threshold [MCT]) were estimated and applied to differences in BRX versus placebo (PBO) at hour 60 (primary endpoint) and day 30 (end of trial follow-up). Likelihood of HAMD-17 response and remission and Clinical Global Impression of Improvement (CGI-I) response for BRX versus PBO were assessed at hour 60 and as sustained through day 30 using relative risk. Associated number needed to treat (NNT) and number needed to harm (NNH) values were also estimated. Results: Two-hundred nine patients were included. The average HAMD-17 MID estimate was -2.1; the least-squared mean difference between BRX and PBO exceeded this at hour 60 and day 30. Minimal, moderate, and large MCTs were estimated to be -9, -15, and -20 points, respectively. Significantly more BRX-treated than PBO-treated patients achieved minimal, moderate, and large change (all ps < 0.05) at hour 60 and large meaningful response at day 30 (p < 0.05). BRX-treated patients were more likely to sustain HAMD-17 remission and CGI-I response through day 30 versus PBO. NNTs ranged from 4 to 8, with NNH of 97. Conclusions: BRX provided meaningful changes relative to PBO, rapid (hour 60), and sustained improvements (day 30) in PPD symptoms, low NNT, and large NNH. These results may help inform treatment decision-making. Clinicaltrials.gov registration numbers: NCT02614547, NCT02942004, and NCT02942017.

Case Report: Implementation of a Multi-Component Behavioral Health Integration Program in Obstetrics for Perinatal Behavioral Health

Despite growing research and policy attention, perinatal behavioral health conditions (i.e., mental health and substance use disorders) remain prevalent, burdensome for families, and largely untreated in the US. Researchers have documented an array of barriers to accurate detection, linkage with effective treatment, and improved outcomes for perinatal women with behavioral health disorders. It is clear that a multi-component approach that integrates evidence-based detection and management of perinatal behavioral health in the context of obstetrics care can be effective. This paper presents the initial development of a clinical quality improvement program that includes evidence-based components of behavioral health integration in obstetrics in the state of Florida in the US. The FL BH Impact (Improving Maternal and Pediatric Access, Care and Treatment for Behavioral Health) program, guided by the RE-AIM model for program implementation, has been developed over the past 2 years. Program components, initial implementation, and preliminary findings are presented. Following the implementation phase, the program has enrolled 12 obstetrics practices and 122 obstetrics providers in program engagement and training activities. The primary program component allows for obstetrics clinician telephone access to a statewide listing of behavioral health referral resources for patients and access to consultation with psychiatry. Since program implementation, the program has received a total of 122 calls to this line, with an expected increasing trajectory of calls over time. Results suggest this program is feasible to implement across a large geographic area. Challenges to implementation and future directions are discussed. These types of multi-component approaches to improved management and outcomes for perinatal behavioral health are promising and must be expanded and sustained in the US.

Minding the Gatekeepers: Referral and Recruitment of Postpartum Mothers with Depression into a Randomized Controlled Trial of a Mobile Internet Parenting Intervention to Improve Mood and Optimize Infant Social Communication Outcomes

Mothers in the United States (U.S.) who are of non-dominant culture and socioeconomically disadvantaged experience depression during postpartum at a rate 3 to 4 times higher than mothers in the general population, but these mothers are least likely to receive services for improving mood. Little research has focused on recruiting these mothers into clinical intervention trials. The purpose of this article is to report on a study that provided a unique context within which to view the differential success of three referral approaches (i.e., community agency staff referral, research staff referral, and maternal self-referral). It also enabled a preliminary examination of whether the different strategies yielded samples that differed with regard to risk factors for adverse maternal and child outcomes. The examination took place within a clinical trial of a mobile intervention for improving maternal mood and increasing parent practices that promote infant social communication development. The sample was recruited within the urban core of a large southern city in the U.S. and was comprised primarily of mothers of non-dominant culture, who were experiencing severe socioeconomic disadvantage. Results showed that mothers self-referred at more than 3.5 times the rate that they were referred by either community agency staff or research staff. Moreover, compared to women referred by research staff, women who self-referred and those who were referred by community gatekeepers were as likely to eventually consent to study participation and initiate the intervention. Results are discussed with regard to implications for optimizing referral into clinical intervention trials.

Trends in mental health and substance use disorders and treatment receipt among pregnant and nonpregnant women in the United States, 2008-2014

PURPOSE

To compare trends in mental health and substance use disorders and treatment receipt of pregnant and nonpregnant women from 2008 to 2014.

METHODS

Using data from the 2008-2014 National Survey on Drug Use and Health, logistic regression was used to compare trends in mental health and substance use disorders and treatment receipt for mental health and substance use disorders among propensity score-matched groups of pregnant (n = 5520) and nonpregnant women (n = 11,040). Among women in the matched sample who met criteria for at least one mental illness, trends in mental health treatment receipt of pregnant (n = 1003) and nonpregnant women (n = 2634) were compared.

RESULTS

There were no differences in the trends by pregnancy status from 2008 to 2014. Past-year anxiety disorder, past-month psychological distress and illicit drug use disorder increased in the total sample from 2008 to 2014, yet trends in mental health treatment and unmet need for substance use treatment did not change over time. Pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts.

CONCLUSIONS

There is a need for preventive strategies addressing anxiety disorder, psychological distress and illicit drug use among women of childbearing age as well as initiatives to increase access to mental health treatment among pregnant women.

Chinese Women's Acceptance and Uptake of Referral after Screening for Perinatal Depression

China recently issued a national plan on perinatal depression (PND) screening. Previous studies elsewhere suggested that uptake of referral after screening for PND is suboptimal, but little is known in China. In this cohort study including 1126 women in Hunan, we identified women at a high risk of PND using the Edinburgh Postpartum Depression Scale (EPDS) over multiple time points. We texted them and offered free consultations with a psychiatrist/psychologist. Among 248 screen-positive women, only three expressed interest and one attended the appointment. We surveyed the women about their reasons for declining referrals and preferred means of care. Of the 161 respondents, 128 (79.5%) indicated that they could cope with the condition without professional assistance and 142 (88.2%) chose their families as the preferred source of help. Only 15 (9.3%) chose professionals as their first option. Implementing a referral policy for screen-positive women would mean approximately one-third of women who gave birth in China would be eligible. Our result argues against referring all screen-positive women for professional services at this time. Interventions should instead build upon the tradition of family support in a more engaged response. These considerations are relevant for the implementation of national screening for PND in China.

Psychosocial Factors Associated with Paternal Perinatal Depression in the United States: A Systematic Review

Paternal perinatal depression can occur in approximately one out of ten fathers. However, research within this population is limited. A previous systematic review suggested that United States had higher rates of paternal perinatal depression compared to other countries. Therefore, this systematic review identified psychosocial factors for depression during the perinatal period in fathers who live in the United States. A literature search was conducted from multiple databases using keywords and MeSH terms to retrieve articles up to the year 2019. Twenty five articles were included in this review. A social-ecological framework was applied to identify psychosocial factors associated with paternal depression. Individual factors include prior history of depression, having maladaptive cognitive coping styles, fathers who self-identified as African-American or Hispanic, parenting stress, substance use, and history of criminal conviction. Interpersonal factors include lack of social support, quality of relationship with the mother of the baby, coparenting conflict, quality of current and childhood relationships with their own parents, and maternal depression. Community factors include frequent daily experiences with racism, and limited access to transportation and housing. These findings underscore the importance of assessing depression and developing father-inclusive interventions that address the psychological needs of fathers.

Treatment and Management of Depression Symptoms in Pregnant Veterans: Varying Experiences of Mental Health Care in the Prenatal Period

Depression screening is recommended for all pregnant veterans; however, little is known on how often symptomatic women receive care, how depression treatment presents in practice, and whether women veterans are utilizing treatment during the appreciable perinatal period. Our sample included 142 pregnant veterans from 15 Veterans Health Administration (VA) medical facilities with Edinburgh Postnatal Depression Scale (EPDS) scores ≥10. Sociodemographic characteristics, military service, health utilization, and pregnancy related factors were collected as part of a telephone survey. A majority of our sample (70%) had 1 or more mental health visits or antidepressant prescriptions during pregnancy. Women with a history of depression had more mental health visits and a higher percentage of antidepressant use before and during pregnancy than women without a history of depression. Pregnant women veterans without a history of depression may be less likely to receive care for depression during pregnancy. However, the majority of our veterans showing depression symptoms prenatally had at least one mental health visit or an antidepressant medication fill during their pregnancy window, suggesting that mental health care is readily available for women veterans.

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

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

Cost-Effectiveness of Brexanolone Versus Selective Serotonin Reuptake Inhibitors for the Treatment of Postpartum Depression in the United States

BACKGROUND

Brexanolone injection (BRX) was approved by the FDA in 2019 for the treatment of adult patients with postpartum depression (PPD), but its cost-effectiveness has not yet been evaluated.

OBJECTIVE

To estimate the cost-effectiveness of BRX compared with treatment with selective serotonin reuptake inhibitors (SSRIs) for PPD.

METHODS

We projected costs (2018 U.S. dollars) and health (quality-adjusted life-years [QALYs]) for mothers treated with BRX or SSRIs and their children. A health state transition model projected clinical and economic outcomes for mothers based on the Edinburgh Postnatal Depression Scale, from a U.S. payer perspective. The modeled population consisted of adult patients with moderate to severe PPD, similar to BRX clinical trial patients. Short-term efficacy for BRX and SSRIs came from an indirect treatment comparison. Long-term efficacy outcomes over 4 weeks, 11 years (base case), and 18 years were based on results from an 18-year longitudinal study. Maternal health utility values came from analysis of trial-based short-form 6D responses. Other inputs were derived from the literature.

RESULTS

The incremental cost-effectiveness ratio for BRX versus SSRIs was $106,662 per QALY gained over an 11-year time horizon. Drug and administration costs for BRX averaged $38,501, compared with $25 for SSRIs over the studied time horizon. Maternal total direct medical costs averaged $65,908 in the BRX arm, compared with $73,653 in the SSRI arm. BRX-treated women averaged 6.230 QALYs compared with 5.979 QALYs for the SSRI arm. Adding partner costs and utilities in a sensitivity analysis further favored BRX. Results were sensitive to the severity of PPD at baseline and the model time horizon. Probabilistic sensitivity analyses indicated that BRX was cost-effective at the $150,000-per-QALY threshold with 58% probability.

CONCLUSIONS

Analysis using a state transition model showed BRX to be a cost-effective therapy compared with SSRIs for treating women with PPD.

DISCLOSURES

This study was funded by Sage Therapeutics, Cambridge, MA. Eldar-Lissai, Gerbasi, and Hodgkins are employees of Sage Therapeutics and own stock or stock options in the company. Gerbasi also reports previous employment with Policy Analysis Inc. Cohen contributed to this work as an independent consultant. Meltzer-Brody has a sponsored clinical research agreement with Sage Therapeutics to the University of North Carolina, as well as a sponsored research agreement from Janssen to the University of North Carolina, unrelated to this work. Meltzer-Brody has also received personal consulting fees from Cala Health and MedScape, unrelated to this work. Johnson, Chertavian, and Bond are employees of Medicus Economics, which was paid fees by Sage to conduct the research for this study. Study findings do not necessarily represent the views of CEVR or Tufts Medical Center.

Psychosocial Factors Associated With Postpartum Contraceptive Method Use After an Unintended Birth

OBJECTIVE

To examine whether depression, intimate partner violence, and other psychosocial stressors were independently associated with effectiveness level of postpartum contraception among women who recently had an unintended birth.

METHODS

We analyzed cross-sectional data from PRAMS (the Pregnancy Risk Assessment Monitoring System) to identify women who had an unintended birth between 2012 and 2015. The effectiveness level of the contraceptive method was coded into one of five categories based on the postpartum contraceptive method that women were using: none, less effective (withdrawal, rhythm, condoms, or other barrier), moderately effective (pill, patch, ring, or shot), long-acting reversible contraception (LARC; intrauterine devices or implants), and sterilization (female or male sterilization). Multinomial logistic regression was used to examine whether prepregnancy depression or elevated postpartum depressive symptoms, intimate partner violence before or during pregnancy, and number of psychosocial stressors before birth were associated with effectiveness level of method (compared with no method), in models adjusted for sociodemographics, pregnancy context, and postpartum context.

RESULTS

Complete data were available for 56,445 (88.2%) of the 64,030 eligible women: 24.2% experienced depression; 5.3% experienced intimate partner violence; and 16.8% experienced five or more psychosocial stressors around the time of pregnancy or birth. In adjusted models, experiencing intimate partner violence and more stressors lowered women's relative risk of using sterilization, LARC, moderately effective methods, and less-effective contraceptive methods relative to no method use. Only prepregnancy depression was associated with using sterilization compared with no method use.

CONCLUSIONS

Experiencing intimate partner violence and having more psychosocial stressors were each independently associated with not using a postpartum contraceptive method. Standardized screening for psychosocial factors during prenatal and postpartum care should be integrated, and practices that encourage the discussion of patients' psychosocial experiences and postpartum contraception use together are warranted.

Depression, Anxiety, and Substance Use Disorders and Treatment Receipt Among Pregnant Women in the United States: A Systematic Review of Trend and Population-Based Studies

The objective of this systematic review was to synthesize findings of trend and population-based studies on depression, anxiety, and substance use disorders and treatment receipt among pregnant women in the United States. Twenty-eight articles (nine trend studies and 19 population-based studies) were included for review. Two trend studies showed that illicit drug use disorder increased in pregnant women over the past decade, particularly opioid and marijuana use disorders. Three studies reported an increase in treatment admissions for these disorders from 1992 to 2012; however, the overall treatment admission rate for pregnant women remained relatively stable at 4%. Three studies identified an increase in antidepressant use from 1995 to 2010 in pregnant women. Nine of 19 population-based studies revealed that White ethnicity, older reproductive age, college education, and health insurance coverage were associated with mental health and substance use treatment receipt among pregnant women. Further studies are warranted among a nationally representative sample of pregnant women.