Journal of Psychosomatic Obstetrics & Gynecology, 2012; 33(4): 143–161 © 2012 Informa UK, Ltd. ISSN 0167-482X print/ISSN 1743-8942 online DOI: 10.3109/0167482X.2012.728649 J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Strategies for improving perinatal depression treatment in North American outpatient obstetric settings Nancy Byatt1, Tifany A. Moore Simas2, Rebecca S. Lundquist3, Julia V. Johnson4 & Douglas M. Ziedonis3 1 Department of Psychiatry and Ob/Gyn, 2Department of Ob/Gyn and Pediatrics, 3Department of Psychiatry, and 4Department of Ob/Gyn, UMass Medical School, Worcester, MA, USA and other substances [6]. Postpartum depression is associated with ofspring attachment insecurity [7], and diicult infant and childhood temperament [2,7]; long-term consequences include developmental delay, impaired language development [3,4] and depressive, anxiety or disruptive disorders [5]. hese negative impacts can be mitigated by efective treatment of maternal illness [15]. In extreme cases, perinatal psychiatric illness can be fatal and lead to the tragic consequences of suicide [1] and infanticide [16]. In some regions in Canada, untreated maternal depression has been estimated to cost over $20,000,000 annually [17]. Perinatal depression refers to minor or major episodes of depression occurring during pregnancy and the irst twelve months postpartum [14,18,19]. In spite of profound negative efects on mother and child that are mitigated by efective treatment of maternal illness [15], perinatal depression remains under-diagnosed and under-treated in obstetric settings [20–26]. Due to regular contact with obstetric providers and women’s preference [27,28], the obstetric setting seems an ideal place to detect and manage depression. Programs that integrate depression and primary care through screening, patient education, feedback, and case management improve outcomes in primary care settings [29]. Recognizing this, the American College of Obstetricians and Gynecologists (ACOG) [30,31] and others [18,32–35] advocate that obstetricians screen for psychosocial stressors and depression every trimester and provide resources and referrals when indicated. Screening improves detection of perinatal depressive symptoms [36], yet does not improve treatment entry [37–39] or outcome [38,39]. Screening is intended to capture women at increased likelihood of experiencing perinatal depression. A positive screen indicates the need for an assessment by a qualiied provider to conirm or exclude a diagnosis of depression [40] and determine if treatment is indicated. Despite high acceptance of depression screening among Objective: To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment. Method: Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment. Results: Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources. Conclusion: Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment. Keywords: Depression, facilitators, perinatal, postpartum, pregnancy Introduction Perinatal depression can cause signiicant sufering for mother, fetus/child and family [1–7]. In spite of the negative impact, barriers to the treatment of perinatal depression persist [8–13]. Up to 18.4% of women sufer from depression during pregnancy, and as many as 19.2% of mothers develop a depressive disorder [14]. Untreated depression during pregnancy is associated with poor birth outcomes and long-term efects on the mother, child, and family. Depressed pregnant women are more likely to have poor weight gain and engage in poor health behaviors including abuse of alcohol, tobacco Correspondence: Dr Nancy Byatt, DO, MBA, UMass Medical School, Psychiatry and Ob/Gyn, 55 Lake Ave North, Worcester, MA 01655, USA. E-mail: nancy.byatt@umassmemorial.org 143 J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. 144 N. Byatt et al. women, many are not amenable to additional contact with a mental health provider [22,27,41,42]. Studies [22,27,41,42] indicate that less than 30% of women who screen positive for depression attend an initial or subsequent mental health visit with some studies indicating rates as low as 6 [27] and 0% [42]. his lack of treatment engagement may be due to under-involved providers and staf [43] and limited resources to ensure accurate depression diagnosis, treatment, and follow-up [33]. Screening for perinatal depression is feasible [44,45] and increases detection and treatment rates [46–48] when coupled with systematic changes to ensure women receive appropriate care [44–48]. his suggests that clinical, programmatic, and system-level changes are needed to optimize perinatal depression treatment. An integrated approach could overcome such barriers to addressing perinatal depression in obstetric settings, and thus is the focus of this paper. he purpose of this article is to: (1) identify core barriers and facilitators to addressing perinatal depression; (2) review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment in obstetric settings, and; (3) propose speciic strategies and innovative program models for addressing perinatal depression in the outpatient obstetric setting. Methods We conducted a literature search in the English-language literature indexed on MEDLINE/PubMed for the period between 1966 and 2012. We searched using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression, matching each with the following 21 terms: treatment, barriers, facilitators, integrated, obstetric, physician, provider, training, attitudes, access, collaborative care, stepped care, co-located, consultation, motivational interviewing, motivational enhancement intervention, organizational change, program, performance improvement, policy, and service delivery. All articles were cross-referenced, to identify other relevant articles not identiied in the initial search. Abstracts of all papers identiied were reviewed. Original studies, including pilot, qualitative and clinical trials were included. Abstract exclusion criteria were the following: not perinatal depression related, no discussion of barriers and/ or facilitators to perinatal depression treatment, and no discussion of interventions in obstetric settings aimed to engage women and/or providers in treatment. Full-text articles were reviewed to ensure compliance with inclusion and exclusion criteria. Articles that explored barriers and facilitators to perinatal depression were categorized by speciically identiied barriers or facilitators. Interventional articles were classiied as those providing clinical level versus programmatic versus systematic interventions. Results Systematic searches yielded an initial identiication of 7768 papers, many of which were duplicates. We identiied 49 papers relating to barriers and facilitators and 1, 13 and 3 papers relating to clinical, program and systems levels interventions, respectively that met study inclusion and exclusion criteria. Barriers Patient level barriers As summarized in Table II, a variety of factors contribute to women’s reluctance to seek and engage in depression treatment during the perinatal period [10,11,13]. As demonstrated in Table I, the available data is limited because the majority [9–13,49–59], yet not all [8,9,60–68] of the studies are qualitative and therefore not generalizable. Despite these limitations, these data provide insight into barriers to treatment and can inform the development and testing of interventions. Some women report they experience the discussion of depression treatment options to be a burdensome task that negatively impact their own and others’ perception of themselves as mothers [10,13,49,57–59,65]. In addition, due to concerns regarding medication use in pregnancy, women worry about pharmacologic treatment options for depression [9,63,66]. Some fear losing parental rights for disclosing depression symptoms [12,13,49,53,58,64]. Other women believe that psychiatric symptoms are an expected part of adjustment to motherhood [10,13,62,63]. Despite regular and routine contact in pregnancy, some women report that their obstetrician does not address their emotional needs and that they perceive their provider as unresponsive or unsupportive [8,12,59,69,70]. Women also report that their psychiatric symptoms are normalized, dismissed as self-limited, or given cursory attention by their obstetric provider [10,12,13,58,59,63,69–71]. Provider level barriers among obstetric providers and staff he majority of obstetricians [72,73] midwives [74], and nurses [74] report they have a responsibility to recognize maternal depression. Unfortunately, this does not result in delivery of care [73] because many factors inluence whether depression will be addressed [73]. Lack of knowledge and skills, identiication as a specialist [66,75–78], and the absence of a systematic referral process [77,79] discourage the integration of depression and obstetric care. hese factors have led some to the misperception that addressing depression is beyond the scope of what can be ofered in an obstetric setting. Obstetric providers and staf report multiple barriers to treating perinatal depression including lack of time, limited knowledge of available resources, and perceived reluctance of their patients to engage in depression treatment [49,66,73,75–82]. he majority of obstetricians [73,83–86], midwives [74,87], and nurses [74] report inadequate or barely adequate training with regards to depression and/or mental health. Untrained obstetric providers and staf are less likely to screen for [66] and/or discuss mental health concerns [66,75–78,87]. Even in well-supported ‘universal screening’ programs with algorithmic decision support and direct interconnectedness with psychiatry, EPDS scores are only documented in 39% of visits, and documentation of provider counseling in 35% of visits [88]. Most obstetricians report being supportive of screening and deem it to be efective [66], yet prefer Journal of Psychosomatic Obstetrics & Gynecology Strategies for improving perinatal depression treatment J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Table I. Summary of studies examining barriers and facilitators. Study/sample size Country Setting Patient level barriers and facilitators Reay et al (2011) [61]. (n = 199) Australia Two public and one private hospital Bennet et al (2009) [8]. (n = 225) United States Jesse et al (2010) [51]. (n = 21) United States Wood et al (1997) [70]. (n = 11) United Stated Edge et al (2004) [55]. (n = 301) England Edge et al (2008) [52]. (n = 12) England Edge et al (2010) [50]. (n = 12) England Edge et al (2011) [69]. (n = 42) England Nahas et al (1999) [54]. (n = 45) Australia Shakespeare et al (2003) [56]. (n = 39) England © 2012 Informa UK, Ltd. Population of women served 145 Study design and methods Women antenatal through 2 years Descriptive study: women postpartum who screened positive for depression (n = 98) and a random sample who screened negative (n = 101) participated in survey at 2 years postpartum. Measures included: mood, treatment access, quality of relationship with partner, coping, and mother-infant bonding. Women receiving obstetric Qualitative study: used Faculty outpatient semi-structured interviews to gynecologic practice and care assess intention to seek help resident obstetric practice from obstetric providers. at large academic medical center Qualitative study: used Prenatal clinic in a rural Low-income African (n = 16) semi-structured focus group southeastern community American and Caucasian interviews to elicit perceived (n = 5) women barriers and facilitators to help-seeking for perinatal depression. Qualitative study: used inCaucasian women previously Women recruited via diagnosed with PPD by a health depth interviews to explore newspaper article and women’s experiences and care provider professional network perceptions of postpartum contacts depression (PPD). Mixed-method study: (1) (1) 101 black Caribbean Large teaching hospital Women completed EPDS women and 200 Caucasian and community and questionnaires; and, (2) British women; and, (2) a antenatal clinics and individual qualitative subset of 12 black Caribbean women representing a full range interviews with a purposeful sample to assess women’s of depression scores (EPDS) completed individual interviews perspectives on perinatal depression and help-seeking. Qualitative study: used Black Caribbean women Large teaching hospital in-depth interviews with a approximately 6 months and community postpartum selected from larger purposeful sample to explore antenatal clinics low treatment and research sample [55] (n = 301) participation rates for perinatal depression. Qualitative study: individual 12 black Caribbean women Large teaching hospital selected from larger sample [55] interviews with a purposeful and community sample to assess women’s (n = 301) representing a full antenatal clinics perspectives on perinatal range of depression scores depression and help-seeking. (EPDS) Community settings Black women of Caribbean origin Qualitative study: 5 focus (e.g. churches) groups with a purposeful sample of 6-10 women to explore low levels of treatment for perinatal depression. Women living in Middle Eastern women Qualitative study: in-depth Sydney, Australia individual unstructured interviews with a purposeful sample to explore experiences of PPD. Qualitative study: in-depth General practices within Postpartum women individual unstructured the Oxford City Primary interviews with a purposeful Care Group sample to explore acceptability of PPD screening by health visitors. (Continued) 146 N. Byatt et al. Table I. (Continued). Study/sample size Holopainen et al (2002) [67]. (n = 7) Country Setting Population of women served Study design and methods Australia Community mental health service Women currently sufering from or had a recent history of PPD Qualitative study: used in-depth interviews to elicit women’s experience of support and treatment for PPD. Qualitative study: 5 focus groups and 10 in-depth individual interviews to investigate barriers to help seeking for PPD. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Abrams et al. 2009 [49]. (n = 37) United States Kopelman et al (2008) [9]. (n = 1416) United States McIntosh et al (1993) [53]. (n = 60) Scotland Kim et al (2010) [11]. (n = 51) United States Callister et al (2011) [115]. (n = 20) United States Goodman, 2009 [60]. (n = 509) United States Slade et al (2010) [65]. (n = 30) England Flynn et al (2010) [97]. (n = 23) United States Henshaw et al (2011) [59]. (n = 23) United States O’ Mahen et al (2008) [91]. (n = 108) United States hree target groups: (1) Women, Infant and culturally and linguistically Children (WIC) federal nutrition program diverse (CALD) women with PPD symptoms year prior (n = 14); (2) community informants; and, (3) health and social care professionals for CALD new mothers (n = 12) 4 maternal health centers Women 6-26 weeks gestational age and a university based OB clinic Prospective study: using a mixed-methods approach women completed measures assessing depression severity, willingness to seek treatment and barriers to care. 3 antenatal clinics First-time mothers Prospective study: assessed women’s perceptions and experiences of the condition and implication on help seeking. Perinatal women ofered mental Prospective study: mixedDepartmental universal methods telephone interview depression screening and health referrals during OB care to examine mental health referral program referral outcomes among antenatal women at risk of depression. Qualitative study: individual Community health clinic Immigrant Hispanic women interviews to identify barriers scoring positive for symptoms to seeking mental health of PPD resources. Descriptive study: Two OB clinics ailiated Women in third trimester of pregnancy questionnaire to examine with a large teaching women’s attitudes and hospital preferences toward depression treatment and perception of barriers to accessing treatment. Qualitative study: in-depth General primary care Women 6 months postpartum interviews to explore practice with EPDS ≥18 at 6-weeks women’s experiences during postpartum identiication and management of depression by health visitors. Pregnant and postpartum women Qualitative study: used Five obstetric clinics: with EPDS ≥ 9 and not receiving semi-structured interviews to 2 university hospital explore perceptions of barriers mental health treatment ailiated and 3 private and facilitators to depression treatment. Pregnant and postpartum women Qualitative study: used Five obstetric clinics: semi-structured interviews not receiving mental health 2 university hospital to explore perceptions of treatment ailiated and 3 private interactions with clinicians and how such interactions afect seeking help for depression. Women seeking prenatal care Descriptive survey study: 4 obstetric clinics: via surveys and structured 1 associated with a interview assessed barriers university hospital and to treatment and conidence 3 part of a nonproit in treatment, providers and organization settings compared between African American and white women. (Continued) Journal of Psychosomatic Obstetrics & Gynecology J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Strategies for improving perinatal depression treatment Table I. (Continued). Study/sample size Country Setting Amankwaa, 2003 [57]. (n = 12) United States Private health care settings Letourneau et al (2007) [63]. (n = 41) Canada Segre et al (2010) [28]. United States Sword et al (2008) [13]. (n = 18) Canada Woolhouse et al (2009) [62]. (n = 1385) Australia 6 metropolitan hospitals Nulliparous women, < 24 weeks gestational age Mauthner et al (1997) [58]. (n = 18) England Community sources Mothers self-identiied as having experienced PPD Chew-graham et al (2009) [93]. (n = 61) United Kingdom 9 Primary Care Trusts in inner city and urban areas 19 general practitioners (GPs), 14 health visitors, and 28 women Women who recently gave birth in Iowa (sample 1) and women enrolled in Healthy Opportunities for Parents to Experience SuccessHealthy Families Iowa (HOPES-HFI) program (sample 2). Public health unit’s Healthy Baby, Healthy children Program Barriers and Facilitators Among Obstetric Providers and Staf Buist et al (2005) [81]. Australia Division of general (n = 246 GPs and 525 women) practice within 34 maternity hospitals/area health services Coleman et al (2008) [84]. (n = 397) United States Buist et al (2006) [80]. (n = 1153) Australia © 2012 Informa UK, Ltd. Population of women served African-American women diagnosed with PPD or by self-report of PPD. Report of depression within 12 Urban city that ofers systematic PPD screening weeks of delivery and program and rural regions without systematic screening Sample 1 (n = 691): white, married, and well-educated postpartum women; sample 2 (n = 132): culturally, linguistically, and economically diverse mothers enrolled in HOPES-HFI Women with EPDS ≥ 12 at 4 weeks postpartum 147 Study design and methods Qualitative study: used individual interviews to examine nature of PPD. Qualitative study: used women semi-structured individual interviews (n = 41) and also focus groups in a subset (n = 11) to elicit women’s views on barriers and facilitators to PPD treatment. Descriptive survey study of two groups to examine model in which nurses’ screen and counsel women for PPD. Qualitative study: used in-depth semi-structured interviews to explore barriers and facilitators to help-seeking for PPD. Longitudinal study: used longitudinal questionnaires and telephone interviews to investigate help-seeking behaviors and barriers to help-seeking for depression. Qualitative study: used semistructured in-depth individual interviews to explore women’s experience s with PPD. Qualitative study: in-depth interviews with subjects participating in a RCT to explore subjects’ perspectives on the disclosure of symptoms indicative of PPD in primary care settings. GPs, women attending 6-12 week Descriptive survey study: postpartum visit surveyed GPs and postpartum women to assess knowledge of, and attitudes toward PPD via case vignettes. Descriptive survey study: Questionnaires mailed to Obstetricians surveyed of obstetricians 1193 obstetricians who diagnostic accuracy for mental were ACOG Fellows and health issues during pregnancy Junior Fellows via clinical vignettes with describing depressive and anxiety symptoms. Random sample of 246 GPs and Survey study: assessed Regions throughout 338 maternal child health nurses awareness and knowledge Australia to be of perinatal depression via (MCHNs) and 569 midwives subsequently targeted responses to a hypothetical involved in perinatal care by a screening and case vignette and knowledge education program questionnaire. (Continued) 148 N. Byatt et al. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Table I. (Continued). Study/sample size Schmidt et al (1997) [85]. (n = 822) Country United States LaRocco-Cockburn et al (2003) [86]. (n = 282) United States Rothera et al (2008) [92]. (n = 41) England Segre et al (2010) [116]. (n = 520) United States Palladino et al (2011) [79]. (n = 20) United States Price et al (2012) [76]. (n = 1498) United States McCauley et al (2011) [87]. (n = 161) Australia homas et al (2008) [72]. (n = 228) United States Logsdon et al (2010) [89]. (n = 43) United States Setting ACOG Fellows Population of women served Obstetricians/ACOG Fellows Study design and methods Exploratory survey study: examined depression diagnosis, treatment, patient referral patterns and professional training in the management of depression via a questionnaire. Used data from the National Center for Health Statistics to validate data on practice patterns. Washington State ACOG Obstetricians /ACOG members Cross-sectional survey: members examined obstetricians’ attitudes and practices to depression screening via a 36-question survey. Qualitative study: conducted: (1) 39 health professionals; 2 strategic health (1) semi-structured interviews general adult and perinatal authorities, 6 health psychiatrists, obstetricians, health with health professionals communities, 4 mental visitors, midwives, GPs, primary via purposeful and snowball health trusts, 12 care mental health practitioners, sampling; (2) 2 focus groups maternity hospitals and with women; and (3) 1 focus and health services managers; 24 primary care trusts group with staf from mother (2) 12 women who had been and baby unit. admitted to a mother-baby unit and had a history of perinatal mental illness; and, (3) staf from mother and baby units Descriptive survey study: Surveys mailed statewide Large and diverse sample of (Iowa) to nurses who met nurses currently working within surveyed nurses to assess acceptance of nurse-delivered women’s health, pediatrics, eligibility criteria postpartum mental health care. community health, general practice, or psychiatry Qualitative study: used Obstetricians, nurses, medical 6 hospital and semi-structured interviews assistants, social workers and community based with each provider to administrators obstetric clinics understand providers’ perception of inluences on perinatal depression care. Statewide health care Physicians, nurse practitioners, Public health survey data settings in Virginia and certiied midwives analysis to evaluate whether constructs within MI were linked with improved depression screening and treatment/referral. Midwives Explorative descriptive survey: Antenatal wards, labor explored midwives attitudes, wards, postnatal units, knowledge, skills, and special care nursery, experiences of working with residential units, mother women with perinatal mental and baby psychiatric unit illness. of 20 hospitals Northern Carolina Random sample of obstetricians Descriptive survey study: examined relationship between and family practitioners Physicians Database characteristics of physicians providing care for postpartum women and their preference for treatment and management of PPD. Cross-sectional, descriptive, Hospital-based perinatal nurses Private suburban in labor and delivery and mother/ correlational study: used hospital in southern self-reports instruments to baby units United States explore relationship between self-eicacy and PPD teaching. (Continued) Journal of Psychosomatic Obstetrics & Gynecology Strategies for improving perinatal depression treatment Table I. (Continued). Study/sample size Country United States Mancini et al (2007) [75]. (women: n = 755; providers: n = 16) Delatte et al (2009) [88]. (n = 47) United States J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Lieferman et al (2008) [73]. (n = 232) United States Setting Collaborative obstetric and midwifery practice Outpatient obstetric practices in an academic medical center Healthcare settings in 5 cities in Virginia Skočir et al (2005) [74]. (n = 134) Slovenia Urban academic maternity hospital and 6 community services Leddy et al (2011) [82]. (n = 223) United States ACOG Edge et al (2010) [77]. (n = 42) England Antenatal community clinics, general practices, large inner-city teaching hospital, and voluntary sector agency specialists Buist et al (2006) [78]. (health professionals n = 916; women n = 860) Australia 43 maternity hospitals and area health services Kim J, et al (2009) [66]. (n = 22) United States Price et al (2012) [76] (n = 1498). United States Physicians practicing obstetrics, pediatrics, or family medicine Employed workers with education in midwifery or nursing education working with perinatal women Fellows and junior fellows of ACOG GPs, midwives, hospital doctors, health visitors, and voluntary sector providers (1) Antenatal and postpartum women receiving care at maternity hospitals; and, (2) GPs (n-229), maternal child health nurse (n = 267), and midwives (n = 305) Academic medical center 19 obstetricians and 3 nurse with private and hospital- midwives employed faculty Health care practitioners in Virginia to screen in the context of structured programs that provide guidance for obstetric providers and access to mental health assessment and referral [66]. A combination of staf training [87,89], structured screening programs, and community resource guides may help obstetric providers and staf feel more comfortable detecting and referring or treating perinatal depression [90]. Provider and staf training in mental health can allow obstetric providers and staf to feel more conident with these discussions [66,84], which may in turn assuage women’s fears and concerns and activate women to engage in a range of treatment options including individual and group psychotherapy [51,58,65,66,75]. © 2012 Informa UK, Ltd. Population of women served 11 obstetricians and 9 midwives serving 200 deliveries per year and 755 postpartum women Obstetric providers Family practice physicians (n = 299), obstetricians (n = 178), pediatricians (n = 250), and other physicians (n = 272), nurse practitioners (n = 213), and certiied nurse midwives (n = 74), registered nurse or social workers (n = 26) 149 Study design and methods Cross-sectional study: examined use of screening tool. Descriptive survey study: examined use of EPDS for detecting PPD. Surveillance study examined relationships among physicians’ knowledge, beliefs, self-eicacy and perceived barriers and practices toward perinatal depression. Descriptive questionnaire survey study: examined conidence to manage PPD. Descriptive survey study: examined obstetricians’ attitudes, knowledge, and practices regarding diagnosis of PPD and postpartum psychosis. Qualitative study: used individual interviews and focus groups to examine health professionals’ perspectives on perinatal mental healthcare for minority ethnic and Black women. Survey to examine acceptability of perinatal screening. Descriptive study: used structured interviews to examine obstetric care provider attitudes toward screening and factors associated with screening. Survey study: public health survey regarding practitioners’ practices and perceptions of perinatal depression care to inform interventions aimed to enhance perinatal depression screening and participation in mental health treatment. Limited mental health treatment resources Available treatment resources are oten limited for both perinatal women and obstetric providers and staf, creating both patient and provider barriers, respectively. Women note numerous factors that impede their ability to seek and access mental health treatment [9–13,49–52,60,64,67, 91–93], including disconnected pathways to depression care [10,13,66,75,77]. Sub-optimal interactions between women and mental health providers also impede engagement in treatment. Mental health providers can be perceived as unresponsive, unavailable [9,11,70] or uncaring [49] by women. To improve their knowledge and skills in treating pregnant 150 N. Byatt et al. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. and postpartum women, additional training on the risks and beneits of pharmacologic and psychosocial treatments for perinatal depression is needed for mental health specialists [18,90,94]. A good irst step is to provide resource and referral source guides for patients and staf. Co-locating mental health care with the obstetric settings may also be an efective way to overcome some of these issues [95]. Provider psychoeducation [51,58] about psychiatric resources [51,58,65] may empower women by increasing their knowledge [68] about available resources including professional, non-professional and self-help resources as listed in Table III. Facilitators Addressing depression in the outpatient obstetrical setting through clinical, program, and system level changes Strategies at clinical, program, and system levels can be utilized to help obstetric outpatient programs better address perinatal depression [11,13,96]. Clinical level interventions target the complex patient-provider relationship through education and other motivational enhancement interventions to improve screening processes and treatment engagement. Program level interventions oten involve a team of providers and/or staf and focus on quality or performance improvement. As summarized in Table IV, many facilitators have been identiied by women and obstetric providers in qualitative and descriptive studies as presented in Table I. Examples of program level enhancements include changes in referral and screening processes, provider/staf training, and eforts that provide more patient and family centered care [8,11,13,60,66,92,97]. Improved clinical documentation “triggers” within an electronic medical record [66] and increased monitoring of clinical outcomes can be useful in promoting culture changes that help providers and staf address depression [18]. Broader system-level interventions can occur within or in collaboration with agencies or across multiple programs. For example, interventions or policy changes aimed to combine mental health and perinatal care could improve alliances, partnerships and promote seamless perinatal depression care in outpatient obstetric settings. Clinical level interventions Providers and staf can be trained to combine screening with education and other motivational enhancement interventions that may inspire women to engage in treatment. For example, information about health risks, wellness interventions, available support groups, psychotherapy, medication, and other community resources can encourage women to address their depression. Motivational Interviewing (MI) is a patient-centered interviewing style that helps clinicians to successfully promote behavioral change in a wide variety of medical and behavioral circumstances. MI can improve medication compliance, initiation and maintenance of new behaviors, discontinuation of harmful behaviors [98], and treatment engagement and retention [99]. A recent survey of perinatal healthcare providers examined programmatic theory components of a MI intervention. While limited by inherent measurement error, small sample size of speciic provider groups, and recruitment of subjects from one geographic area, the results support the use of MI as an intervention that may positively inluence provider practices and attitudes toward perinatal depression screening and treatment [76]. Program level interventions Program level interventions include staf training and implementation of universal screening with structured and stream-lined referral processes aimed to integrate depression and obstetric care [18]. Such program level interventions are needed because systematic screening and referral alone do not translate into treatment engagement [42]. While several of the available studies summarized in Table V have promising data [44,45,95,100], the available studies examining perinatal depression program level interventions in obstetric settings are limited by lack of comparison groups. Additionally, many studies do not assess treatment participation or depression outcomes among women and most do not provide data on why women did or did not engage in treatment. For example, a Perinatal Depression Management Program [45] introduced stepped-care management through on-site diagnostic assessment in obstetric clinics. In stepped-care models, screening, diagnosis and treatment begin in a primary care setting and if depression persists, the patient is ofered additional follow-up, monitoring, patient education, support, mental health consultation and/or referral by a care manager [101]. In the Perinatal Depression Management Program, 72.0% of women who screened positive received on site diagnostic assessment; this is signiicantly greater than previous studies [22,27,41], results of 0 [42] to 30% [27,41] rates of subsequent mental health assessment or follow-up in screen positive women. While the former results are promising, it is diicult to draw conclusions without a comparison group, without reported depression outcomes among women, and without assessed or even speculated reasons for their high acceptance rate of onsite diagnostic evaluations [101]. As part of a similar stepped-care approach [100], the Perinatal Mental Health Project implemented training for perinatal health care workers, routine antenatal depression screening, and a referral network to on-site counselors and mental health professionals. While the project demonstrated the approach to be feasible and acceptable, it also lacked a comparison group and did not assess depression outcomes or reasons for high acceptance rates among women [100]. Although not speciic to obstetric providers and staf, a randomized controlled trial in family medicine and pediatric clinics compared steppedcare to usual care; stepped-care improved mothers’ awareness of depression and increased the likelihood of getting treatment, yet did not impact duration of treatment, work or health outcomes [64]. his study is limited by its small sample size and inclusion of women with other chronic mental illnesses. Another depression screening program [44] utilized screening with nursing and physician education, a hotline stafed by mental health workers, a mental health provider network to accommodate referrals, and a centralized referral system in 20 private and employed obstetric groups. Department-based, perinatal depression screening was feasible when done with the necessary infrastructure to respond to at-risk patients [44]. However, they did not assess the satisfaction of women and providers, impact on treatment duration and follow-through, or depression diagnosis among women. Journal of Psychosomatic Obstetrics & Gynecology J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Strategies for improving perinatal depression treatment 151 Table II. Barriers to perinatal depression treatment. Patient level Barriers Lack of time [11,60,62,64], transport and/or childcare [9,49,50,60,61,64,91] Unfamiliarity with depression and/or perinatal depression [9,10,13,52,54,55] Unawareness or lack of access to mental health treatment options or resources [8,9,53,54,60,61,63,91] Concerns about risks of medication use in pregnancy or lactation [9,63,66,93] Perception that can work through things herself [11,52,57,62,64] or that other supports can be used [11,49] Lack of motivation and hopelessness about treatment working [62,91] Waiting until symptoms resolve on their own [10,13,57,62–64] Normalization of depression symptoms [10,13,62,63] Discomfort or avoidance of mental health discussions [10,13,57,63] Stigma [9,10,12,49–57,60–63,66] Fear of failing as a mother [10,13,49,57–59,65] or losing parental rights [12,13,49,53,58,64] Fear of being judged by providers [9,12,49,53,58,59,65] Negative prior experiences with mental health treatment [9,12,49,50] Family and friends discourage help seeking [9,10,12,13,49,53,64] Cultural/language barriers [49,57,60] Fear of psychiatric hospitalization [9] Women perceive obstetric providers as unresponsive and/or unsupportive [8,12,59,69,70] Women feel symptoms are minimized or dismissed as self-limited by health care providers [10,12,13,58,59,63,69–71] Perception that midwives are afraid to discuss depression [58] Perception that obstetricians are not qualiied and/or do not want to treat depression [8,70] Perception that obstetric and mental health care are not related and obstetricians is not the typical doctor for depression [8] Lack of time [11,60,62,64], transport and/or childcare [9,49,50,60,61,64,91] Provider level barriers among obstetric providers and staf Obstetricians under-detect depression [63,86] Low depression (44%) screening rates [86] Focus on infant, rather than mother [69] Lack of time to address psychological needs [8,69] Lack of continuity [8] Nurse midwives perceive that clinical settings prioritize health of children over maternal health [49] Obstetricians [66,75,76], and midwives [75,77,78] feel they lack the needed skills needed to discuss depression Obstetricians perceive women are unwilling to talk about mental health issues [73,75] and concerned about stigma [73] Liability concerns [73] Obstetricians [73,75,79,82] and nurse midwives [49,75] perceive lack of time [66,77,82], resources [66,77], referral sources [66], and inadequate reimbursement [76] Self-identiication as a specialist associated with lower screening rates [85] Lack of screening documentation [88] or oice prompt to screen [66] Lack of counseling about depression by providers [88] Obstetricians [73,79,82,84–86] and midwives [78,87] report inadequate or barely adequate training Midwives uncertain how to diferentiate reaction to external stressors from PPD symptoms [49] Lack of lexible and easy referral system [66,75–77,79] Lack of responsibility for arranging mental health follow-up among obstetricians [73] Obstetricians report being skeptical about eicacy of screening [66] and/or perceive woman as unwilling to accept medications, receive counseling or accept diagnosis [82] Limited Mental Health Treatment Resources Diiculty with cost [60] Long wait times for mental health appointment [9] Women do not know who to call or where to go for help [9] Disconnected pathways to depression care[10] Lack of mental health providers willing to see pregnant women [79] Long wait times for mental health appointment [77] A tertiary referral obstetric hospital in Australia developed an Early Motherhood Services (EMS) which included: (1) community educational activities to increase awareness among women and families; (2) resources for women and health care providers; (3) co-located or home treatment for © 2012 Informa UK, Ltd. women and consultation to health care provider; and, (4) education, training and capacity building for providers [95]. While the reduced depression severity in the subset of women who engaged in the EMS [95] suggests that EMS is a promising program, the study design has weaknesses that preclude 152 N. Byatt et al. Table III. Resources for perinatal depression. Telephonic Support for Women Perinatal Mental Health Consultation Line PPDMoms Hotline J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Parental Stress Line Postpartum Support Warm-line Online Support for Women Postpartum Support International Postpartum Progress Jenny’s Light Parenting Resource Directory La Leche League Telephonic Support for Providers Perinatal Mental Health Consultation Line Online Support for Providers MedEdPPD LactMed Massachusetts General Hospital Center for Women’s Mental Health Support and Training to Enhance Primary Care (STEP)-PPD MotherRisk Postpartum SupportInternational Consultation for health care providers who have questions about the detection, diagnosis and treatment of perinatal depression and anxiety disorders. Consultants are University of Illinois Chicago faculty and staf clinicians: psychiatrists, an advanced practice nurse and a social worker. Available support 24 hours a day, 7 days a week for the mothers and their family and/or friends. Ofers support, information and referrals. A statewide parental stress-line that is available 24 hours a day, 7 days a week; stafed by trained volunteer counselors who are sympathetic and non-judgmental. Conidential information, support and listings of local resources. Women can leave a message and a volunteer will return call within 24 hours. (800) 573-6121 Information for mothers, family and professionals. here is a weekly Phone Chat with an expert. Provides educational material and resources. Provides educational resources and peer-to-peer support. An extensive community resource guide for families; online and at libraries and other locations. Information on Family Centers, Housing, Medical and Food assistance, and social activities. International organization dedicated to providing information and support to pregnant and breastfeeding women. www.postpartum.net (800) PPDMOMS or (800) 773–6667 (800) 632–8188 (866) 472–1897 postpartumprogress.com www.jennyslight.org www.parentingdirectory.org www.lalecheleague.org Consultation for health care providers who have questions about the detection, diagnosis and treatment of perinatal depression and anxiety disorders. Consultants are University of Illinois Chicago faculty and staf clinicians: psychiatrists, an advanced practice nurse and a social worker. (800) 573–6121 Web site developed with the support of the National Institute of Mental Health (NIMH) to provide education about postpartum depression (PPD). Includes screening tools, interactive case studies, literature, provider tools, CME modules, and resources. A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible efects on breastfed infants and on lactation, and alternate drugs to consider. Online perinatal and reproductive psychiatry information center. Web-based education to give primary care providers up-to-date information on evidence-based approaches for assessing and treating PPD. Website includes case studies, interactive video clips, didactic information and links to additional resources. Provides educational material and resources. Information for mothers, family and professionals. here is a weekly Phone Chat with an expert. www.mededppd.org any irm conclusions about its success, including absence of a comparison group, bias toward women who engaged in treatment, and lack of data on women who did not engage in treatment. Several other studies examining co-located obstetric and perinatal depression care initiatives [32,102], supportive toxnet.nlm.nih.gov www.womensmentalhealth.org www.step-ppd.com www.motherisk.org www.postpartum.net psychotherapy and case management services [103], and nurse delivered feedback and referrals for perinatal depression [42] show that these interventions may increase the likelihood of seeking treatment. hese studies however, are limited by small sample size, lack of comparison groups and lack of data on depression outcomes and reason for treatment Journal of Psychosomatic Obstetrics & Gynecology J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Strategies for improving perinatal depression treatment 153 Table IV. Facilitators to perinatal depression treatment. Women Encouragement to attend treatment [11] Recognition of depression [63] and mental health needs [11,58,63,69] and support [67] Flexible referrals tailored to patient needs [9,11,12,59,69] Active facilitation of referral process by providers [10,11] Referral process with minimal steps required [10,58] Timely mental health appointment [9–11,13] Family, friend, partner [9,10,12,13] or health provider [9,12] support Mental health treatment in the home [9] or obstetric clinics [9,28,60] Providers who facilitate trust [51,65] and are genuine, warm and optimistic [59] Feeling heard by provider: feeling unjudged, listened to and autonomous [58,75] Reassurance from providers that feelings are common [51] and treatable [63] Psychoeducation [51,58] and resources from providers [51,58,65] Involvement of family nurse [67] Insurance match [11] De-stigmatizing depression [9,59,75] Open discussion about depression before and ater birth [58] Discussion of screening results by obstetric providers or staf [75] Depression counseling from obstetric nurses, physicians or social workers [28] Obstetric providers and staf Obstetricians and midwives [66,75] report being more satisied when they have additional contact and feedback from mental health providers Self-eicacy among nurses [89] Access to mental health assessment [66] Standardized screen that is easy to use [66] Increased depression awareness among women and obstetric health care professionals [66] Established oice prompt for screening [66] Integration of screening into established clinic procedures [66] Invested point person “champion” [66] Setting expectations [66] Nurse-delivered counseling ater depression screening [116] engagement. Other studies examining the impact of training [68,104] and CME courses [105] on perinatal health care providers do not assess what led or did not lead to increased mental health literacy and have methodological limitations that may introduce sample bias. System level interventions System level changes go beyond one obstetrical program or site and may include many obstetrical programs or systems working with other providers, including those from the mental health arena. For example, in 2006 a systems level intervention was federally funded in the United States in the states of Illinois, Iowa, Kentucky, Louisiana, Massachusetts, and Pennsylvania; they each participated in a 2-year project to develop and evaluate novel approaches to improve detection and treatment of perinatal depression and anxiety. While providers were able to acquire and retain the knowledge and skills needed for diagnosis and treatment of perinatal depression and anxiety disorders [106], it did not examine the impact on provider knowledge and attitudes, and patient outcomes; it was subject to further survey bias. As summarized in Table VI, several other disciplines have implemented and tested system level changes to address issues similar to that of perinatal depression. he Massachusetts Child Psychiatry Access Project (MCPAP) provides an example of a © 2012 Informa UK, Ltd. partnership with psychiatry that helped pediatricians with child and adolescent psychiatric cases [107]. MCPAP’s driving goal is support of the pediatrician as a front line provider of mental health care; it does this by providing pediatricians with rapid access to child psychiatry training, referral assistance, and expertise [107]. Due to its remarkable success, 95% of Massachusetts pediatricians are enrolled in MCPAP and MCPAP has expanded to become the National Network of Child Psychiatry Access Programs [108]. Despite MCPAP’s accepted subjective success, similar to other studies its quantiied results are based on unvalidated survey data and sufer from absent comparison groups and patient outcome data. Regardless, this approach is felt to be innovative, sustainable and an industry standard from which aspects could be modeled and adapted to address perinatal depression in obstetric settings. Another example of a successful organizational change model is the Addressing Tobacco hrough Organizational Change (ATTOC) program [109], which has helped agencies integrate and adapt their treatment culture to address wellness and addiction using patient-centered recovery. In comparing staf and clients pre- to -post intervention, staf beliefs became more favorable toward treating tobacco addiction and both prescription dispensing and use of tobacco treatment increased [110]. However, this data is limited by subjects living in residential treatment programs only, small number of J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Health Care Setting, Country, and Population served. Maternity unit of a university hospital in France that has approximately 4800 deliveries per year. Study Jardi et al (2010) [104]. Intervention Tested hree-hour midwife training program and posters that conveyed PPD treatment recommendations. Leddy et al (2012) [105]. Increased rates of screening and use of validated screening measures among CME course takers. CME courses not associated with change in obstetricians’ knowledge and behaviors toward PPD/ postpartum psychosis. (1) Data available for 375 of 537 (1) Average of (SD) 6.81 (6.75) referred to EMS; (2) 296 women days between referral and irst completed EPDS at Time 1 and assessment; (2) Of the 101 women, the initial EPDS was [mean 172 at Time 2; 168 completed (SD) = 13.75 (5.75)], higher than EPDS at Time 1 and 2. 60% the EPDS on discharge was [mean (n = 101) scored one page 13. (SD) = 4.52 (2.74) t ((176) = 2.39; (3) 107 women seen by EMS p < .00005). (3) 84.1% of women were surveyed. (n = 90) strongly agreed and 15.9% agreed (n = 17) they were satisied with the services [mean (SD) = 4.84 (0.37)]; 79.3% strongly agreed (n = 79) and 26.2% agreed the treatment helped them [mean (SD) = 4.74 (0.44)]. 449 (8.8%) of 4,038 antenatal Depression screening program Private and employed physician Reviewed results of depression 4,322 of 9,178 women comwomen screened positive for pleted 4,558 screens over two groups in an obstetrics and gyne- screening (28 and 32 weeks with nursing and physician depression. 7.3% of 520 postparcology department in the United gestation and 6 weeks postpar- years. education, a hotline stafed by tum screens were positive. Crisis tum) program implemented at mental health workers, a mental States serving approximately hotline received 524 calls, 328 20 outpatient obstetric practice 1,000 deliveries per year. provider network to women referred to urgent care/ settings. accommodate referrals, triage, of which 16% were not and a centralized scoring clinically indicated, 11% were and referral system. already in mental health treatment, 6% declined referrals, and 4% could not be given referrals because they were out of state. (Continued) Judd et al (2011) [95]. Journal of Psychosomatic Obstetrics & Gynecology Gordon et al (2006) [44]. Study Design and Methods Two-stage pre-and-post controlled study. Midwives assessed before and ater training to determine correlation between: (1) early clinical assessment by midwives and EPDS; and, (2) postpartum week 1 clinical assessment and MINI DSM IV interview. Continuing Medical Education American College of Obstetri- Descriptive survey study. Compared knowledge, (CME) courses on PPD. cians and Gynecologists attitudes, and behaviors (ACOG) in the United States. regarding PPD and postpartum psychosis in CME course takers versus non-CME course takers. Stakeholder evaluation, analysis Perinatal care provided via a Early Motherhood Services (EMS): provided resources and shared care model with GPs or a of available outcome data and co-located or home treatment for midwifery care model provided consumer feedback. Stakeholder evaluation: interviews women, mental health consulta- in a small regional city in with stakeholders. Outcome tion for health care provider, and Australia to perinatal women. data evaluation: compared education, training and capacity EPDS and HoNOS (Health of building for providers. the Nation Outcomes Scale) scores at the time of referral to EMS (Time 1) to the EPDS at discharge (Time 2). Consumer feedback: subset of consumer completed 7-item feedback survey ater discharge from EMS. n Before training (control group): 472 postpartum women in the maternity unit; 112 with EPDS >10 and random sample of 120 women with EPDS <10 Ater training (intervention group): 343 postpartum women; 112 with EPDS >10 and 110 with EPDS <10. 400 obstetricians who were fellows or junior fellows of ACOG completed survey. Findings Ater training, early detection of major depressive episodes increased by 37.7% (95% CI: 25.7–49.7). Detection of minor depression did not increase. 154 N. Byatt et al. Table V. Program level interventions. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. © 2012 Informa UK, Ltd. Table V. (Continued). Study Gjerdenjen et al (2009) [64]. Intervention Tested Stepped collaborative care model; screening and diagnosis in clinic and if depression persists, additional follow-up, monitoring, patient education, support, mental health consultation or referral by a care manager is ofered. Miller et al (2009) [45]. Perinatal Depression Management Program (PDMP): on-site diagnostic assessment in obstetric clinics, expert mental health consultation to obstetric providers, reference guidelines for prescribing of antidepressants, systematic referral to mental health setting when indicated, and a Quality Monitoring system to track women screened in the perinatal care setting. Federally Qualiied Health Center in Chicago in the United States serving > 16,000 patients and > 1,000 birth per year. Clinical staing included family practice physicians (4 full time equivalent, or FTE), midwives (4 FTE), obstetricians (2.1 FTE), pediatricians (2.1 FTE), internists (1.0 FTE), nurse practitioners (1.0 FTE), and a social worker (1.0 FTE), all luent in English and Spanish. Clinic population is 94% Mexican American, 90% Spanish-speaking. 90% are at or below the 200% federal poverty level, and 13.2% unemployed. Perinatal Mental Health Project A secondary level, university ailiated maternity hospital in (PMHP): training for health an urban setting, Cape Town, care workers, routine antenaSouth Africa. Provides care to tal depression screening, and ~ 150 women with low obstetreferral networks to on-site ric risk from surrounding areas counselors and mental health per month. professionals. Study Design and Methods Randomized controlled trial: depressed women randomized to stepped care or usual care. 9 month health, work, and treatment outcomes evaluated for stepped care versus usual care, and women self-diagnosed with depression versus nondepressed. Case Study of PDMP: examined feasibility and acceptability of PDMP. Examined screening. referral and treatment rates. n 506 women completed surveys at 0,1,2,4,6 and 9 months postpartum and a SCID. 5 women had SCID-positive depression and 122 had selfdiagnosed depression. Of 45 SCID-positive women, 19 participated in stepped care and 20 participated control group. 35.1–84% of 2191 women screened per month. Findings Improved mothers’ awareness (n = 19) of depression and increased likelihood of getting treatment compared to usual care (n = 20); did not signiicantly impact duration of treatment, work or health outcomes. Case study of PMHP: examined acceptability and feasibility of PMHP. 90% of 6347 women ofered screening with EPDS and Risk Factor Assessment (RFA). Of 95% (n = 5407) screened, 32% with EPDS ≥ 13 were referred to a counselor and 62% (n = 1079) agreed to be referred. 1,981 counseling sessions conducted and 2% (n = 20) were referred to a psychiatrist. Women received an average of 2.7 counseling sessions, 832 of which were irst sessions. 88% of subjects reported being more able to cope with their presenting problem due to the counseling. (Continued) Of 17.1% of women needing further assessment, 72.0% received on site diagnostic assessment. High acceptance rate (98.6%) of on-site diagnostic screen. Strategies for improving perinatal depression treatment Honikman et al (2012) [100]. Health Care Setting, Country, and Population served. 4 urban university-ailiated family medicine residency clinics, 3 suburban, private pediatric clinics in the United States during well-child visits. 155 J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. 156 Table V. (Continued). Intervention Tested HS CARES (Healthy Start Collaboration for Assessment, Referral, Evaluation, and Stabilization): screening and co-located perinatal depression care. Kuosmamen et al (2010) [32]. PPD screening and treatment in maternity and child health clinics: Co-located cognitive behavioral therapy-with a mental health nurse. PPD Intervention Program: (1) postpartum EPDS screening; and, (2) individualized intervention (supportive therapy and counseling in perinatal depression) using a case management multidisciplinary team model. Systematic depression screening and referral. Chen et al (2011) [103]. Rowan et al (2012) [42]. Journal of Psychosomatic Obstetrics & Gynecology Buist et al (2007) [68]. Flynn et al (2006) [117]. Health Care Setting, Country, and Population served. A university-based research clinic with a focus on perinatal mood disorders in the United States. Served pregnant and up to 1 year postpartum Healthy Start clients. 3 maternity and child health clinics in Finland serving 550 births per year. 2 outpatient obstetric clinics in Singapore, providing care to 2000 postpartum women annually at 2-6 weeks post delivery. Large multi-specialty organization with 19 clinics and over 300 physicians in the United States, serving an ethnically diverse population of over 400,000 patients. Study Design and Methods Feasibility study: examined screening and treatment rates in women with a conirmed diagnoses of depression (via EPDS and PRIME-MD) Case study: examined screening, referral and treatment rates among women with EPDS ≥13 at 8-week postpartum visit. Prospective cohort study: measures taken at baseline (irst intervention) and a 6 months or discharge. Feasibility study: examined detection, referral, and treatment rates. Compared responses to hypothetical depression case and depression risk and help seeking behavior using EPDS between women who participated in screening (Group 2) program and those that who had not (Group 1). Longitudinal study: pregDepression screening with sys- University hospital obstetrics nant women with EPDS ≥10 clinic in the Unites States tematic follow-up: (1) treating physician notiied of EPDS ≥10; serving privately insured (87%), completed study interviews at baseline, 1 month ater (2) nurse-delivered depression Medicaid (10%) and self-pay/ baseline and 6 weeks other (3%). feedback and referral. postpartum. Enhanced PPD screening: (1) screening program; (2) training and support for midwives, MCHNs, GPs and a range of student health in how to discuss mental health issues; and, (3) educational booklet. 43 maternity hospitals/area and district health services, mainly in public university-based hospitals and some private, rural and remote locations in all states and 1 territory in Australia. Findings 55% (n = 16) participated in the evaluation and 50% (n = 8) attended ≥ 1 follow-up visit. Women who attended the follow-up visit found medication and skills training reduced their symptoms and enhanced their functioning. 53% of women (n = 88) had 1-2 166 with EPDS ≥13 at 8 week meetings with health nurse, 22% postpartum visit participated in mental health nurse sessions. attended 3-8 meetings and 25% (n = 41) attended 1 group meeting. 95% satisied with screening and 2148 eligible women; 64% 71% with educational interven(n = 1367) participated in tion, 31% (n = 42) accepted screening. referral to psychiatrist and 32.5% (n = 41) participated in PPD intervention. n 29 women with EPDS ≥10 agreed to enter CARES program. 2199 eligible women; all 2199 participated in screening at the irst prenatal visit and 569 participated at the 6-week postpartum visit. 1309 women; 414 in Group 1, of which 394 completed majority of questionnaire, 895 in Group 2, of which 612 completed majority of questionnaires. 1298 women screened with EPDS, 16% (n = 207) scored ≥10, 60 women completed all interviews. Of the 2199; 18.7% (n = 412) had an EPDS score ≥9 and 4.6% (n = 102) had an EPDS score ≥14 and none followed the recommendation to seek behavioral health assessment. Of the 569 that participated in postpartum screening; 4.9% (n = 28) had an EPDS score ≥14 and 17.9% (5 of the 28) followed recommendations to seek behavioral health care. Response rates 57% for Group 1 were 62% and for Group 2. Group 2 was better able to recognize depression (60.4% vs. 47.1%) in a hypothetical case and to assess their own mental state than Group 1, yet it was not statistically signiicant. 65% of women with MDD were not receiving treatment, the 67% (n = 49) reported physician discussed depression and were more likely to seek treatment by the 1 month prenatal follow-up but not at the 6 week postpartum follow-up. N. Byatt et al. Study Sit et al (2009) [102] J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. © 2012 Informa UK, Ltd. Table VI. System level interventions. Study Obstetric Setting Shade et al (2011) [106]. Guydish et al (2012) [110]. Country and Health Care Setting and Population Served Study Design and Methods n Findings 1,679 providers in Illinois and nearly 1,500 in Pennsylvania in the United States. Piloted and tested provider education strategies: assessed provider knowledge pre- and post-workshop. 77 obstetric providers, 92 maternal and child health staf. Ability to name a validated depression screening tool increased from 27.2% (n = 28) to 96.2% (n = 99) among providers (n = 103). Knowledge of obstetric risks of untreated antenatal depression increased from 18.4% (n = 19) to 87.3% (n = 90) among providers (n = 104). Ability to correctly understand Food and Drug Administration pregnancy risk categories increased from 9.4% (n = 9) to 79.2% (n = 76) among providers (n = 96). Knowing a source of evidence-based information about antidepressants during pregnancy and breastfeeding increased from 30.6% (n = 29) 78.5% (n = 77) among providers (n = 98). Knowledge increased from 63% (n = 47) before the workshop to 87% (n = 47) at the end of the workshop and was 81% (n = 26) at 8-week follow-up. Massachusetts Child Psychiatry Access Project (MCPAP): (1) combination of real time telephonic psychiatric consultation, care coordination services and professional education. Hosted by a division of child psychiatry within regional academic medical centers in Massachusetts in the United States. MCPAP team consists of ~1 full-time (FTE) equivalent psychiatrist, 1 FTE child and family psychotherapist, and 1 FTE care coordinator. Measured MCPAP provider participation and utilization over 3.5 years for 35,335 encounters. 1341 primary care clinicians in 353 practices; 514 (38%) completed baseline survey. Of 524, 385 (75%) completed follow-up survey(s). 10,114 children served by MCPAP. Addressing Tobacco hrough Organizational Change (ATTOC) utilizes seven core strategies: (1) activities related to preparation for initiation of the intervention, (2) on-site tobacco treatment specialists (3) identiication of ATTOC leaders, (4) work group formation to carry out the 12-Step ATTOC approach (5) in person consultation and (6) ongoing phone consultations for expertise and advice, and (7) web based training and support. hree large multi-service addiction treatment organization agencies with residential addiction treatment programs in three states in the United States. Evaluated 6 month ATTOC intervention: surveyed program and staf and clients pre- to post-intervention, and at 6 month follow-up. Site 1: 54 staf and 40 clients Site 2: 43 staf and 50 clients, Site 3: 17 staf and 20 clients. > 90% respondents in year 1 and 2 agreed or agreed strongly that MCPAP consultations were useful. Percentage that agreed there was adequate access to a child psychiatrist increased from 5–33%. Percentage who agreed or strongly agreed they were able to meet the needs of child with psychiatric problems increased from 8–63% and the % able to obtain child psychiatry consultation in a timely manner increased from 8–80%. Staf beliefs became more favorable toward treating tobacco dependence (F(1, 163) = 7.15, p = 0.008) and use of nicotine replacement treatment increased. Client attitudes toward treating tobacco dependence also became more favorable (F(1, 235) = 10.58, p = 0.0013) and clients received more tobacco-related services from their program (F(1, 235) = 92.86, p < 0.0001) and counselors (F(1, 235) = 61.59, p < 0.0001). 157 Integrated Obstetric and Mental Health Care Program: (1) provider-education (training workshop); (2) infrastructure-building and interventions to improve service-delivery; (3) screening and treatment tools; and, (4) access to consultation with specialists. Strategies for improving perinatal depression treatment Other Settings Sarvet et al (2010) [107]. Intervention Studied 158 N. Byatt et al. clinical sites, small sample size with potential for confounding by factors such as local or state changes in tobacco policies, and lack of patient outcome data. Recognizing these limitations, several of ATTOC tactics could be adapted for perinatal depression, for example the use of improved documentation of assessment and treatment, integration of screening tools, and psychosocial treatment oferings. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. Discussion With rising public health concerns about perinatal depression, the development of a successful multidisciplinary approach that includes strategies to enhance clinical, program, and system level change is paramount. Obstetric settings and practices have a unique opportunity to address perinatal depression. While there are clear barriers to addressing perinatal depression, there are also efective ways to address these barriers while promoting the integration of obstetric and mental health care. Training of all relevant health professionals and staf is imperative for successful implementation of screening programs that engage women in treatment [18], yet it needs to be supplemented with additional programmatic changes. While midwife training [104] and obstetrician Continuing Medical Education courses on postpartum depression (PPD) [105] have been associated with increased rates of detection [104], and screening rates [105], such training has not been associated with change in obstetricians knowledge, attitudes and behaviors toward PPD [105]. Implementing PPD screening with education is not enough to engage women in interventions targeted to treat depression [37]. In order to improve treatment participation, screening programs must go beyond simply screening and integrate obstetric and depression care. Stepped-care models, in which screening, diagnosis and treatment begin in a primary care setting, may provide a model for perinatal depression care in the obstetric care setting [101]. Access to women’s mental health providers could be improved by increasing availability via telephone consultation, one-time patient consultation, ongoing treatment within mental health programs and co-location of psychiatric services within obstetric clinics [60,95]. Improvement can be monitored through peer audits of clinical charts, referral tracking and self-report scales [111]. Successful treatment outcomes communicated via newsletters, websites, and other mechanisms can provide evidence that treatment leads to enhanced mental health for baby, mother, and family. Strategies used to sustain change include policy changes and the creation of standard operating procedures [112]. Programs that provide treatment for perinatal women will have their own unique treatment culture with inherent challenges. For example, in the perinatal setting, barriers related to staf include lack of training, misconceptions, and beliefs that depression does not fall within their treatment purview [66]. Strategies that engage both providers and women in treatment can facilitate identiication and referral to treatment among obstetric providers. Obstetric provider discussions of depression with patients is not enough; it impacts treatment entry in the short-term, yet not in the long-term [10]. Other facilitators include provider training [90,109,113], structured universal screening and referral, linked obstetric and mental health medical records [45,100,106] and increased access to resources for women. Enhanced provider training can lead to improved detection and less misconceptions and stigma surrounding mental health treatment. Interventions aimed to improve obstetric knowledge base and communication skills, may result in improved screening and referral rates. Nursing staf can also be utilized to perform screening and provide psycho-education. Social work, nursing and clerical staf can be trained to make the referral process seamless, lexible and timely to decrease women’s perception that mental health providers are not responsive or available. Routinely ofering depression treatment in obstetric clinics can enable providers to form liaisons with mental health providers and ease the referral process, while providing a low stigma setting in which their patients can obtain care. System Integration Programs such as the Integrated Obstetric and Mental Health Care Program, Massachusetts Child Psychiatry Access Project, and Addressing Tobacco hrough Organizational Change ofer models to address the mental health needs of perinatal women and the environments in which they get care. Finally, screening will be more successful if accompanied by a clear role for obstetricians as to how to refer and/or manage treatment. System changes likely include the need for enhanced collaborations and possibly the need for memoranda of agreement. Funding for system change is oten more complicated and can require State or Federal level funding support. With changes in health care reform, large agencies and networks are making system changes to improve quality of care and reduce costs. he delivery of treatment for perinatal depression could be improved through new evidenced-based policies and legislation aimed to change how health care is organized. Examples include legislation that establishes mental health parity with physical illness, and the establishment of inancial support for perinatal depression care from public and private insurers [114]. Despite a substantial body of evidence suggesting that strategic changes are greatly needed to successfully refer and engage perinatal women in depression treatment, there remains a dearth of information on how to successfully do so. Future studies should extend previous work on patient barriers by focusing on complex patient-provider interactions contributing to untreated perinatal depression. Obstetric providers should be supported in their role as front line providers to perinatal women through structured universal screening and referral, provider training and consultation, and supervision with mental health professional collaboration. Future program-level interventions should aim to integrate depression screening and treatment into routine perinatal care through organizational changes that aim to increase access to and engagement in perinatal depression treatment. Declaration of interest: he irst author has received grant support for perinatal depression research from the Meyers Primary Care Institute/Rosalie Wolf Interdisciplinary Geriatric Healthcare Research Center Small Grants Initiative. Journal of Psychosomatic Obstetrics & Gynecology Strategies for improving perinatal depression treatment he second author has no declarations of interest. his third author’s spouse is a research scientist working in the pharmaceutical industry. He currently works for Ininity Pharmaceuticals and in the past ive years has worked for Biogen and Pizer. he fourth author has no declarations of interest. he ith author has received research funding support from the NIH, Legacy Foundation, Massachusetts Department of Mental Health, Connecticut Department of Public Health, and SAMHSA. J Psychosom Obstet Gynaecol Downloaded from informahealthcare.com by University of Massachusetts on 11/29/12 For personal use only. References 1. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health 2005;8:77–87. 2. Britton HL, Gronwaldt V, Britton JR. Maternal postpartum behaviors and mother-infant relationship during the irst year of life. 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Current knowledge on this subject • Despite the deleterious efects of perinatal depression, barriers hinder screening, assessment, and treatment in the outpatient obstetrical setting. • Depression is oten not fully integrated into obstetrical care. • Major changes in current practice patterns are needed to improve treatment for perinatal depression. What this manuscript adds • Identiies barriers to addressing perinatal depression, including lack of provider training, limited mental health resources, and fears among women and providers. • Identiies facilitators to perinatal depression treatment including validating and empowering interactions with health care providers for women, obstetric provider training, standardized screening and referral processes, and improved mental health resources. • We critically reviewed clinical, programmatic, and systems level interventions regarding perinatal depression and based on available literature, recommend changes at each level for optimization of recognition and treatment in obstetric settings. © 2012 Informa UK, Ltd.