Background
Methods
Problem identification
Objectives
Literature search
Search Terms | |
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“family practi*” OR “family physician” OR “family practice” OR “physicians, family” OR “primary health care” OR “physicians, primary care” OR “family doctor” OR “general practi*” AND “mental disorder” OR “adjustment disorder” OR “affective disorder” OR “dysthymic disorder” OR “mood disorder” OR psychiat* OR “behaviour control” OR “psychological phenomena” OR depression OR “mental health” OR “stress disorder” OR “anxiety disorder” OR “maternal welfare” OR “maternal health” OR “mental hygiene” OR bipolar OR “obsessive compulsive disorder” OR psychosis OR “psychological distress” OR “somatic disorder” OR “somatoform disorder” OR “mental illness” OR “emotional distress” OR “emotional care” OR “maternal distress” OR “psychosocial wellbeing” OR PTSD OR OCD AND antenatal OR antepartum OR prenatal OR pregnancy OR perinatal OR postnatal OR postpartum OR puerperal. |
Data extraction and evaluation of data
Title, Author, publication year and country | Study aim | Design | Sample strategy and sample size | Data collection method | Analytical approach | Strengths and /Limitations | Key findings reported by authors |
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Recognition and management of perinatal depression in general practice. Buist et al. (2005), Australia [28]. | To identify ways to improve detection and access to treatment. | A cross- sectional survey. | A random sample of 1075 general practitioners (GPs). Response rate (n = 246, 22.9%). A convenience sample of 908 women. Response rate (n = 525, 57%). | Questionnaire (10 multi-choice questions) and vignette. | Descriptive and inferential statistics (Analysis of Variance). | Random sample of general practitioners (GPs). Low response rate of 22.9% but consistent with other GP study response rates. Reliability and validity of the questionnaire and vignette not reported. | GPs preferences for antidepressant medication (antenatally 77% and postnatally 97%) contrasted strongly to women’s preferences for antidepressant medication (antenatally 22% and postnatally 54%). Perceived barriers to all treatments included unavailable resources, time, language or beliefs, reluctance of women to disclose mental health issues and denial/non-acceptance by women. |
Are family physicians appropriately screening for postpartum depression?. Seehusen et al. (2005), Washington [27]. | To determine how frequently Washington state FPs screen for PPD, what methods they use to screen and what influences their screening frequency. To explore FPs’ beliefs, attitudes and feelings concerning PPD and what screening tools they use. To identify factors associated with increased screening. | Cross-sectional survey. | A Random sample of 594 FPs. Response rate (n = 362, 60.9%). | A 25-item questionnaire developed for the study. Pilot tested for face validity. | Frequencies (X2 analysis, Multiple logistic regression, Bivariate analysis). | Random sample of FPs. Good response rate of 60.9%. Respondents were recruited from the Washington Academy of Family practice, a professional society, where members may be more likely to be aware of and follow recommendations for screening. Questionnaire tested for face validity only. Women and younger physicians responded disproportionately to the survey which may have led to an over estimation of screening rates. | 71% of FPs were always or often screening for postpartum depression (PPD) at routine postpartum gynaecologic visits and 46% at well child visits, with 30.6% using a validated screening tool and of those, 82% used a standardised clinical interview. A significant number of respondents believed that screening at every postpartum visit (19.2%) and well-child visit (34.9%) would take too much effort. A variety of tools are used to screen for PPD. Formal training on PPD was received from a variety of sources. |
Health professional’s knowledge and awareness of perinatal depression: Results of a national survey. Buist et al. (2006), Australia [29]. | To evaluate the extent to which perinatal mood disturbances are recognised. | A cross- sectional survey. | A random sample of 1075 GPs. Response rate (n = 246, 23%). A random sample of 610 Maternal Child Health Nurses. Response rate (n = 338, 55%) A random sample of 995 Midwives. Response rate (n = 569, 57%). | A 10-item knowledge questionnaire based on work of Watts and Pope (1998) and a depression vignette based on work of Jorm et al. (2000). | Descriptive and inferential statistics (ANOVA, t-tests). | Random sample of GPs. Low response rate of 22.9%. Reliability and validity of the questionnaire and vignette not reported. | GPs had similar positive awareness scores for perinatal depression compared to both midwives and maternal child health nurses. Depression more likely to be considered postnatally. In relation to the vignette GPs were more likely than MCHNs and midwives to provide an accurate diagnosis (91.1% v 81.7% and 79.3% respectively). The greatest difference among health professionals was in the use of antidepressants with GPs being significantly more likely to choose these in comparison to MCHNs or Midwives (95% CI 8.4–23.2 and 20.9–34.3 respectively). |
GPs’ and health visitors’ views on the diagnosis and management of postnatal depression: a qualitative study. Chew-Graham et al. (2008), UK [30]. | To explore the views of GPs and health visitors (HV) on the diagnosis and management of postnatal depression. | A qualitative study nested within a multicentre randomised controlled trial (RESPOND trial). (Underpinning methodological approach not identified). | Purposive sample. GPs (n = 19). HVs (n = 14). | In-depth, semi-structured interviews. | Thematic analysis (Strauss 1986). | Nineteen GPs participated in the study however data saturation, informed consent and relationship between researcher and participants were not addressed. | Psychosocial aetiology was attributed to the cause of PPD and ambivalence about the status of PPD as a separate condition was identified. GPs relied on instinct or clinical intuition to alert them to the possibility of PPD. There was a reluctance to actively look for PPD or label a woman with PPD because of lack of referral options available. GPs identified the health visitor as a support for the woman. |
Primary Care Physicians’ Beliefs and Practices toward Maternal Depression. Leiferman et al. (2008), USA [19]. | To better understand and identify potential differences in attitudes, beliefs, efficacy, practices and current barriers (i.e. patient, physician and system) toward managing maternal depression across primary care specialities. | Cross-sectional survey. | A convenience sample of 971 primary care providers (PCPs). Response rate (n = 232, 23.9%). Response rate Obstetricians (n = 49, 22.6%), Paediatricians (n = 81, 37.3%) and family medicine practitioners (n = 87, 40.1%). | 60-item questionnaire developed for the study (web or mail). Content validity by expert panel and pilot tested. | Descriptive and inferential statistics (Chi-square and one-way ANOVAs). | Convenience sample with response rate of 40.1% (n = 87). Reliability of questionnaire not determined. | Screening: 29.9% of family medicine physicians never/rarely assessed for maternal depression and 70.1% screened monthly/weekly/daily. The majority of family medicine physicians treat maternal depression by prescribing medication (92%) followed by referral to the mental health specialist off-site (82.8%) and 70.1% provide counselling in office and 37.9% refer to community support groups. The most commonly reported barriers that reduce the likelihood of screening and treatment for depression across specialities were limited time, patient barriers (perception that patient was unwilling to talk about mental health issues and the perception of stigma), lack of knowledge and skills and responsibility for follow-up care. |
Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study. Chew-Graham et al. (2009), UK [31]. | To explore GPs, health visitor’s and women’s views on the disclosure of symptoms which may indicate postnatal depression in primary care. | A qualitative study nested within a multi-centre pragmatic randomised controlled trial (RESPOND trial). (Underpinning methodological approach not identified). | Purposive sample. GPs (n = 19). HVs (n = 14). Women (n = 28). | In-depth, semi-structured interviews. | Thematic analysis (Strauss 1986). | Nineteen GPs participated in the study however data saturation, informed consent and relationship between researcher and participants were not addressed. | GPs were reluctant to use the label PPD with women because of the stigma that they perceived women felt and the effect this would have on the consultation and because they felt women would recover without formal interventions. A lack of user-friendly health services or referral options, limited appointment availability, lack of continuity of care and feeling antidepressants were the only treatment options were identified as barriers to management. GPs identified offering a return visit as a strategy to support women presenting with PND. |
Depression during pregnancy: views on antidepressant use and information sources of general practitioners and pharmacists. Ververs et al. (2009), The Netherlands [22]. | To investigate whether GPs and pharmacists in the Netherlands obtain information on the safety of gestational drug use and the pharmco-therapeutic approach when managing depression and anxiety during pregnancy. | Cross-sectional survey. | A random sample of 700 GPs and 700 pharmacists. Response rate GPs (n = 130, 19%). Pharmacists (n = 144, 21%). | 20 - item Questionnaire developed for the study. | Descriptive and inferential statistics (chi-squares tests). | Random sample of GPs. Low response rate of 19%. Reliability and validity of the questionnaire not reported. | GPs consulted a variety of sources for information on drugs during pregnancy. Variable practices in relation to referral were identified with 29% of GPs in this study never referring a woman who is pregnant and on anti-depressants to a psychiatrist and 50% some-times refer. The main reason for treating depression or anxiety during pregnancy was because the severity of maternal complaints outweigh possible risks for the child (n = 124). A lack of knowledge was evident around the consequences of perinatal depression. |
Falling through the net- Black and minority ethnic women and perinatal mental healthcare: health professionals’ views. Edge (2010), UK [32]. | To investigate health professionals’ views about perinatal mental healthcare for Black and minority ethnic women. | Qualitative study (Underpinning methodological approach not identified). | Purposive sample of 42 healthcare professionals. Third sector (Focus group, n = 3). Specialist midwives (in-depth interviews, n = 2). Hospital midwives (Focus group, n = 9). Community midwives (Focus group, n = 11). Midwifery managers (Focus group, n = 5). GPs (In-depth interview, n = 5). Health visitor (Focus groups, n = 5). Hospital doctor (in-depth interview, 2). | In-depth, semi-structured interviews. | Framework analysis (Ritchie et al. 1994). | Five GPs participated in this study. Data saturation, informed consent and relationship between researcher and participants were not addressed. Appropriate data verification strategies were identified. | Perinatal depression was not routinely screened for during antenatal and postnatal visits to the GP. It was acknowledged that postnatal depression in women from black and minority communities was rarely diagnosed and may be missed. GPs appeared highly resistant to using validated screening tools and valued intuition to identify women with current symptoms of PMHPs in preference to screening tools. Lack of confidence, competence and training in identifying and managing perinatal mental health problems irrespective of ethnic or cultural backgrounds was reported. Lack of cultural competence in services, timely access to appropriate care and the absence of clearly defined care pathways were identified as barriers to the provision of effective perinatal mental healthcare. |
Primary care physician’s attitudes and practices regarding antidepressant use during pregnancy: a survey of two countries. Bilszta et al. (2011) Canada and Australia [23]. | To explore primary care physician’s beliefs and practices toward perinatal depression by investigating the knowledge, attitudes and practices affecting a physician’s decision to continue or discontinue a woman’s antidepressant medication during this period. | A cross- sectional survey. | A convenience sample of 188 primary care physician from Australia (GPs (77)) and Canada (FPs (111)). Response rate Australian GPs (n = 61, 79.2%). Canadian FPs (n = 35, 31.5%). | Questionnaire developed for the study. | Descriptive and inferential statistics (Chi-square test of association with Fisher’s exact test). | Different sampling strategies used for different populations. Convenience sample with response rate of 79.2% (Australian GPs) and 31.5% (Canadian FPs). Australian GPs were attending training workshops about identification, treatment and management of depression and were a self-selected sample. Reliability of questionnaire not determined. | Perceived levels of misinformation about the safety of antidepressant medication in pregnancy, belief that pregnant depressed women should be treated differently from non-pregnant depressed women, concerns over the legal liability and patient concerns influence prescribing practices for GPs and family physicians. |
Antidepressants for mothers: What are we prescribing? Kean et al. (2011) Scotland [34]. | To investigate current prescribing practices among GPs of antidepressants to mothers presenting in first trimester of pregnancy and during breastfeeding. | A cross-sectional survey. | A convenience sample of 78 GPs. Response rate (n = 32, 41%). (methodological approach not clear). | Questionnaire (two vignettes) developed for the study. | Microsoft excel. Descriptive statistics. | Convenience sample with response rate of 41% (n = 32). Reliability and validity of questionnaire not determined. | One in four GPs (n = 8) recommended a class of antidepressants rather than a specific drug. One in ten GPs preferred not to prescribe an antidepressant and one in four would avoid ‘all drugs’. Reasons for avoiding antidepressants included lack of practitioner experience (n = 7), higher teratogenicity risk (n = 5) and lack of data (n = 4). |
A qualitative study into how guidelines facilitate general practitioners to empower women to make decisions regarding antidepressant use in pregnancy. McCauley and Casson (2013), Northern Ireland [33]. | To develop an in-depth understanding of GPs’ experience of using guidelines in the treatment of perinatal depression and if this enabled them to empower women to become involved in treatment decisions. | Qualitative study (Underpinning methodological approach not identified). | Purposive sample of GPs (n = 8). | In-depth, semi-structured interviews. | Colaizzi’ (1978) process of analysis. | Eight GPs participated in this study. Data saturation was not addressed. One data verification strategy (verification of themes between the chief investigator and researcher) was identified. | GPs reported low usage of guidelines. Treatment decisions involved balancing the impact of the severity of symptoms with the possibility of adverse effects of antidepressants on the fetus and timing of treatment. GPs acknowledged the support available from the local mental health team and voluntary organisations. A lack of specific, available resources, specialists’ perinatal mental health services, delays in response due to lengthy appointment waiting lists and increasing workloads were identified as barriers to complicated treatment decisions. |
Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. Santos et al. (2013), Brazil [36]. | To describe primary healthcare physicians’ and nurses’ knowledge and experience in screening and treating women with postpartum depression. | Qualitative descriptive. | Purposeful sample. Physicians (n = 7). Nurses (n = 10). | In-depth, semi-structured interviews. Observation of contacts between HCPs and postpartum women –observation guide developed for study. | Inductive content analysis (Hsieh and Shannon 2005). | Seven physicians participated in this study and the researchers discussed data saturation. Observations of contacts between HCPs and postpartum women supported data findings. Appropriate data verification strategies identified. The relationship between researcher and participants was not addressed. | Physician’s reported limited knowledge, awareness and recognition of PPD and had limited direct clinical experience of caring for women who experience PPD. The focus of care was on physical wellbeing. PPD were seen as the responsibility of psychiatrists in relation to identification, diagnosis and treatment. A lack of specific guidance, training, skills, time and resources were identified as barriers to the provision of care to women with perinatal mood disorders. |
Primary Care Physicians’ Attitudes Toward Postpartum Depression: Is It Part of Their Job. Glasser et al. (2016) Israel [35]. | Israeli primary care physicians’ attitudes and practice regarding postpartum depression (PPD). | Cross sectional survey. | A convenience sample of 345. Response rate 65% (n = 224 paediatricians and family practitioners). Family practitioners (n = 102). Paediatricians (n = 122). | Questionnaire developed for study. | Descriptive and inferential statistics (Chi-square). | Convenience sample with response rate of 65% (n = 224). Reliability and validity of questionnaire not determined. | Family practitioners identified the importance of being able to recognise the signs of PPD. While 84.6% of family practitioners would become somewhat involved to include clarifying the situation, keeping attentive, consulting with colleagues and/or referring the mother to another professional. 83% would be willing to use a brief questionnaire to identify women with signs of PPD. |
Authors | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Total scores |
---|---|---|---|---|---|---|---|---|---|---|---|
Chew-Graham et al. (2008) [30] | Yes | Yes | Yes | Yes | Uncleara | Unclear | Unclearb | Yes | Yes | Clear | 7/10 |
Chew-Graham et al. (2009) [31] | Yes | Yes | Yes | Yes | Uncleara | Unclear | Unclearb | Yes | Yes | Clear | 7/10 |
Edge (2010) [32] | Yes | Yes | Yes | Yes | Uncleara | Unclear | Unclearb | Yes | Yes | Clear | 7/10 |
McCauley and Casson (2013) [33] | Yes | Yes | Yes | Yes | Uncleara | Yes | Yes | Yes | Yes | Clear | 9/10 |
Santos et al. (2013) [36] | Yes | Yes | Yes | Yes | Yes | Unclear | Yes | Yes | Yes | Clear | 9/10 |
Study | 1a | 2a | 2b | 2c | 2d | 3a | 3b | 3c | 4a | 4b | 5a | 6a | 7a | 8a | Total score |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Buist et al. (2005) [28] | Yes | Yes | Yes | Yes | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 11/14 |
Seehusen et al. (2005) [27] | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 13/14 |
Buist et al. (2006) [29] | Yes | Yes | Yes | Yes | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 11/14 |
Leiferman et al. (2008) [19] | Yes | Yes | Noa | Yes | Yes | Yes | Yes | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 12/14 |
Ververs et al. (2009) [22] | Yes | Yes | Yes | No | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 10/14 |
Bilszta et al. (2011) [23] | Yes | Yes | Noa | Yes | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 10/14 |
Kean et al. 2011 [34] | Yes | Unclear | Noa | No | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 8/14 |
Glasser et al. (2016) [35] | Yes | Yes | Noa | No | No | Yes | Unclear | Unclear | Yes | Yes | Yes | Yes | Yes | Clear | 9/14 |
Analysis of data
Presentation of results/findings
Results
Buist et al. (2005) [28] | Knowledge and awareness Anti -depressants Barriers Interventions Barriers to screening- time Referrals | Mean knowledge score out of 100 was 66. General practitioners (GPs) had significantly higher positive awareness of perinatal depression (7.1, SD:2.7) and corresponding low negative awareness (− 0.2, SD: 2.3) compared with the postnatal women surveyed in this study (4.0, SD:3.5 and 1.1, SD: 1.7) (p < 0.0001). In response to the vignette GPs preferences for antidepressant medication (antenatally 77% and postnatally 97%) contrasted strongly to women’s preferences for antidepressant medication (antenatally 22% and postnatally 54%). Women’s preferred treatment options were for natural remedies in comparison to GPs preference for antidepressant medication. Perceived barriers to all treatments included unavailable resources (47%), family language or beliefs (23%), reluctance of patient (19%), None (18%), Financial (12%), denial/non-acceptance of patient (12%) and community attitudes (6%). GPs beliefs around the usefulness of interventions for perinatal depression identified antidepressant medication as a third choice behind counselling and partner support for the woman. Time was identified as the main negative impact of treating depression. GPs reported making referrals to mother –baby unit (68%), counsellor (69%) and psychiatrist (85%), midwife (42%), telephone/crisis line (12%), naturopath (3%). |
Seehusen et al. (2005) [27] | Time of screening Screening tools Training Factors influencing screening Barrier to screening - time | The majority of family physicians (FPs) were screening at routine postpartum gynaecologic visits but not at well child visits. A variety of tools are used to screen for postpartum depression (PPD). 30.6% used a validated tool. The standardised clinical interview was used by the majority of those who screen (82%) followed by The Beck Depression Inventory questionnaire type tool (29%). Formal training on PPD was received in a variety of venues (residency, medical literature and through continuing medical education conferences) Being female, belief that PPD is common enough and serious enough to warrant screening, training in PPD during residency and medical literature review and disagreement that screening takes too much effort were significantly associated with more frequent screening at postpartum gynaecological visits and well-child visits. A significant number of respondents believed that screening at every postpartum visit (19.2) and well-child visit (34.9%) would take too much effort. |
Buist et al. (2006) [29] | Awareness Diagnosis Antidepressants | GPs had similar awareness scores for perinatal depression compared to both midwives and maternal child health nurses. Depression more likely to be considered postnatally. In relation to the vignette GPs were more likely than MCHNs and midwives to provide an accurate diagnosis (91.1% v 81.7% and 79.3% respectively) The greatest difference among health professionals was in the use of antidepressants with GPs being significantly more likely to choose these rather than MCHNs or Midwives (95% CI 8.4–23.2 and 20.9–34.3 respectively) |
Chew-Graham et al. (2008) [30] | Conceptualisation of postnatal depression Screening Referral options Treatment strategies Support strategies Responsibility | Psychosocial aetiology was attributed to the cause of postnatal depression (PND) and ambivalence about the status of PND as separate condition was identified. GPs relied on instinct or clinical intuition to alert them to the possibility of PND. There was a reluctance to actively look for PND or label a woman with PND because of lack of referral options available. GPs used a variety of strategies to care for women and described how the label they used for the woman’s problems determined what management strategies they employed. GPs identified the Health visitor as a support for the woman however some GPs reported observing an unwillingness of some health visitors to care for women with postnatal depression. National policy and local organisations changes impacted on care with no one health professional assuming overall responsibility for the care of women with postnatal depression. |
Leiferman et al. (2008) [19] | Responsibility Confidence Screening Prescribing medication Counselling/referral Community support groups Barriers to screening Knowledge and skills Responsibility Screening tool Referral Barriers to treatment Training | Family medicine physicians were most likely to feel responsible for and confident in treating maternal depression in comparison to obstetricians and paediatricians. Screening: 29.9% of family medicine physicians never/rarely assessed for maternal depression and 70.1% screened monthly/weekly/daily. Use of screening tools: mean 2.40 (SD 0.89). 92% of family medicine practitioners typically treat maternal depression by prescribing medication followed by referral the MH specialist off-site (82.8%) and 70.1% provide counselling in office and 37.9% refer to community support groups. The most commonly reported barriers that reduce the likelihood of screening for depression across specialities were limited time, patient barriers (perception that patient was unwilling to talk about mental health issues and the perception of stigma), lack of knowledge and skills and responsibility for follow-up care. Over 90% of family medicine physicians reported a willingness to implement a screening tool and to place a two-item tool on an intake form. Referral: 62.8% reported never/rarely referring patients for treatment for maternal depression. The most commonly reported barriers to treatment of maternal depression across specialities were limited time, lack of knowledge and skills and responsibility for follow-up care and liability issues. Training: overall PCPs perceived mental health resources to be inadequate. Over 90% of PCPs expressed a willingness to learn about ways to enhance patient communication about mental health issues. More training on mental health issues in the form of continuing education units, guidelines, seminars, workshops and computer deliverables was desired across PCPs. |
Chew-Graham et al. (2009) [31] | Conceptualisation of PND Screening Label Stigma Services Referral options Antidepressants Label Support strategy Barriers to disclosure Barrier to care provision | Psychosocial aetiology was attributed to the cause of postnatal depression and ambivalence about the status of postnatal depression as separate condition as compared with depressive illness at other times in a woman’s life was identified. GPs relied on instinct or clinical intuition to alert them to the possibility of PND. There was a reluctance to actively look for signs of PND or use screening instruments. GPs were reluctant to use the label for PND with women because of the stigma that they perceived women felt and the effect this would have on the consultation and because they felt women would recover without formal interventions. Other reasons identified were a lack of services or referral options and feeling antidepressants were the only treatment options. However, other GPs describe consultations where women were happy to accept the label PND. GPs identified offering a return visit as a strategy to facilitate a discussion and support women presenting with PND. However, they identified barriers that hinder disclosure including not user-friendly health services and limited appointment availability. Some GPs reported consciously inhibiting disclosure in order not to be placed in the position of addressing PND. Lack of continuity of care was identified as a barrier to care provision. |
Ververs et al. (2009) [22] | Guidelines Treatment decisions- pharmacists Sources of information on antidepressant use in pregnancy Guidelines Manufacturers of specific drugs Internet Education Referral Treatment decision Antidepressants Treatment decision Management Antidepressant Psychotherapy Knowledge | Only one GP had access to a local written policy on the treatment of depression and anxiety during pregnancy. Almost three quarters of GPs regularly consult pharmacists for information on drugs during pregnancy. The reference used most frequently by GPs is the “Pharmacotherapy Compass” The Dutch National Health Insurance System Formulary issued annually in the Netherlands. Guidelines on the treatment of depression (not specific to pregnancy) issued by the Dutch College of General Practitioners are used to a lesser extent. A quarter of GPs contact the manufacturer of a specific drug for information. 45% use the internet to look for information on scientific evidence or reports from consensus groups. GPs use different sources of information on antidepressant use in pregnancy. One in five answered yes to the question of whether the subject “treatment of depression and anxiety during pregnancy” has been covered during professional education courses. Referral: 29% of GPs in this study never refer a woman who is pregnant and on anti-depressants to a psychiatrist and 50% refer sometimes. 9% of GPs state that they sometimes advice terminating the pregnancy when a woman who uses antidepressants becomes pregnant. 55% of GPs never advised substituting psychotherapy for medication in order to prevent drug exposure to the child. The main reason for treating depression or anxiety during pregnancy was because the seriousness of maternal complaints outweighs possible risks for the child (n = 124). Reasons for avoiding antidepressants during pregnancy were because antidepressants may have negative effects on the unborn child (n = 93), withdrawal symptoms after birth (n = 44) not officially registered for use during pregnancy (n = 39), perceptions that psychotherapy is as effective as antidepressants (n = 36). Large differences in views on the pharmacological management of depression before and during pregnancy reported. A varied pattern of antidepressant use was reported. Most respondents underestimated the lasting effects of psychotherapy. A lack of knowledge was evident around the consequences of Perinatal depression with only 20% of GPs recognising the negative effects of depression and anxiety on a child’s development and on the management of perinatal depression. |
Edge (2010) [32] | Diagnosis Screening Screening tools Lack of confidence, competence Training Barrier to provision of care Care pathways Lack of confidence in Multi-agency team members Relationships Diagnosis Conceptualisation of PND Cultural competence Awareness Language barriers | Acknowledgement that postnatal depression in women from black and minority communities was rarely diagnosed and may be missed. GPs privileged intuition over instrumentation did not routinely screen for PND, and appeared highly resistant to using validated psychiatric measures or screening tools such as the EPDS and PHQ-9. Lack of confidence, competence and training in identifying and managing perinatal mental health problems irrespective of ethnic or cultural backgrounds was reported. Lack of timely access to appropriate care and the absence of clearly defined care pathways identified as barriers to the provision of effective perinatal mental healthcare. Unfamiliarity between multi-agency team members generated lack of confidence in colleagues’ professional competence (linked to NHS reforms where HVs were moved out of general practice and into centralised services). The importance of establishing trusting relationships with Black women to support diagnosis of perinatal depression was identified. It was acknowledged that Black Caribbean women’s psychological responses were linked to their cultural identify in ways that made it difficult for them to ask for and receive help either from health professionals or from social/family resources. Lack of cultural competence in services acted as a barrier to detection of perinatal depression. Lack of awareness of culturally specific issues and some staff appeared to adopt a ‘colour-blind’ approach to caring for women from diverse ethnic groups instead concentrating on language barriers. |
Bilszta et al. (2011) [23] | Factors influencing Prescribing practices Confidence-treatment decision | Perceived levels of misinformation about the safety of antidepressant medication in pregnancy, belief that pregnant depressed women should be treated differently from non-pregnant depressed women, concerns over the legal liability and patient concerns influence prescribing practices with GPs and family physicians reportedly feeling hesitant to prescribe, tapering dosages rather than discontinuing medication (continuation or discontinuation of use of antidepressants in pregnancy). The authors conclude that primary care physicians are not confident about the decision to treat pregnant women with antidepressants. |
Kean et al. (2011) [34] | Antidepressants Factors influencing prescribing practices in pregnancy Factors influencing prescribing practices in breastfeeding Sources of information on antidepressant use in pregnancy and breastfeeding | One in four GPs (n = 8) recommended a class of antidepressants rather a specific drug. One in ten GPs (n = 3) preferred not to prescribe an antidepressant and one in four would avoid ‘all drugs’. The main reasons for choosing antidepressants in the first trimester of pregnancy were practitioner experience of drug (n = 12) and low teratogenicity (n = 10) and perception of drug safety (n = 7). Reasons for avoiding antidepressants included lack of practitioner experience (n = 7), higher teratogenicity risk (n = 5) and lack of data (n = 4). The main reasons for choosing antidepressants for women who were breastfeeding included drug safety (n = 11), practitioner experience of drug (n = 9) and low levels of antidepressants in breast milk (n = 5). Reasons for avoiding antidepressants in breastfeeding included excreted in breast milk (n = 7), lack of data (n = 3) and lack of practitioner experience (n = 3). The main source of information consulted in pregnancy was the British National Formulary (BNF) followed by specialist advice and in breastfeeding the BNF followed by manufacturer’s advice. |
McCauley and Casson 2013 [33] | Lack of time Guidelines Treatment decisions Service user involvement in decisions Barrier to care provision Service user involvement in decisions Treatment decisions Antidepressants Factors influencing treatment practices Support referral options Barriers Service user involvement in decisions | GPs reported low usage of guidelines in practice due to lack of time and the volume of available guidelines. GPs acknowledged that guidelines provide best practice advice, a professional reference point and can be used as a defence against litigation in case of adverse reactions however, guidelines were also identified as generic, lacked specific and clear direction on treatment in the perinatal period, were restrictive and may inhibit flexibility and knowledge resulting in patient need not being met. GPs relied on their own professional experience and knowledge of the individual woman to make complex risk-benefit treatment decisions. Individualised information provision communicated using lay language in both written and verbal formats encouraged women to be involved in the decision –making process. Lack of specific or accurate guidance was described as a barrier to information provision and led to under treatment of pregnant women in general practice. Professional experience was used to determine the level of involvement that women wanted in the decision-making process. Treatment decisions involved balancing the impact of the severity of symptoms with the possibility of adverse effects of antidepressants on the foetus and timing of treatment. Female GPs acknowledged that their personal experience of pregnancy affected decisions. Lack of consultation with GPs by women led to abrupt stopping of antidepressants. GPs acknowledged the support available from the local mental health team and voluntary organisations. However, a lack of available resources, specialists’ perinatal mental health services, delays in response due to lengthy appointment waiting lists and increasing workloads were identified as barriers to complicated treatment decisions. GPs view the involvement of women in treatment decisions as central to women’s empowerment but clinical complexities and the level to which women want to be involved in decisions about medications in pregnancy limit involvement. |
Santos et al. (2013) [36] | Knowledge and awareness Conceptualisation of PPD Guidelines Focus on physical wellbeing Responsibility Barriers to provision of care – training, skills, time, resources Lack of comfort Lack of space | Family physician’s in a city in Brazil reported limited knowledge, awareness and recognition of PPD and had limited direct clinical experience of caring for women who experience PPD. They viewed PPD as an uncommon problem attributed to hormonal changes. The clinical practice protocols available to physicians did not recommend any particular approach to perinatal mood disorders. The focus of care was on physical wellbeing. PPD was seen as the responsibility of psychiatrists in relation to identification, diagnosis and treatment. A lack of training, skills, time and resources were identified as barriers to the provision of care to women with perinatal mood disorders. Two challenges identified were a lack of comfort in approaching women who could potentially be experiencing PPD and lack of physical space for women to be treated. |
Glasser et al. (2016) [35] | Responsibility Recognition of signs Management Referral Screening | The majority of family practitioners identified the importance of being able to recognise the signs of PPD. 84.6% of family practitioners would become somewhat involved to include clarifying the situation, keeping attentive, consulting with colleagues and/or referring the mother to another professional. 91.2% would be willing to use a brief questionnaire to identify women with signs of PPD. |
Identification of PMHPs
Identification of PMHPs
Timing of screening
Study | Screening instrument | Timing |
---|---|---|
Buist et al. (2005) [28] | The Edinburgh Postnatal Depression scale (EPDS) | Postpartum. |
Seehusen et al. (2005) [27] | A standardised clinical interview (82%). The Beck Depression Inventory (29%). EPDS (10%). Zung Depression Scale (8%). Postpartum Depression Checklist (8%). | 31% of family physicians (FPs) always screened for postpartum depression (PPD) at routine postpartum gynaecologic visits. 40% of FPs often screened for PPD at routine postpartum gynaecologic visits. 5.7% of FPs never screened for PPD at routine postpartum gynaecologic visits. 13% of FPs always screened for PPD at routine well child visits. 33% of FPs often screened for PPD at routine well child visits. 15.2% of FPs never screened for PPD at well child visits. |
Buist et al. (2006) [29] | The Edinburgh Postnatal Depression scale (EPDS). | Postpartum. |
Chew-Graham et al. (2008) [30] | Instinct or clinical intuition to alert GPs to the possibility of PPD. | Intuitional use - “So I’m not saying I would actually look for it, but I am hoping my antennae would tell me if there was a problem” (GP, M5, P.171). |
Leiferman et al. (2008) [19] | Evidence of screening tool utilised by participants but screening tool not identified. Use of screening tool: mean 2.40 (SD = 0.89). Over 90% of family medicine physicians reported a willingness to implement a screening tool and to place a two-item tool on an intake form. | 70.1% screened monthly/weekly/daily. 29.9% never/rarely assessed for maternal depression. |
Chew-Graham et al. (2009) [31] | Instinct or clinical intuition to alert GPs to the possibility of PPD. | Intuitional use where a degree of suspicion is present. |
Ververs et al. (2009) [22] | None identified. | N/A |
Edge (2010) [32] | GPs privileged intuition over instrumentation and did not routinely screen for PPD and appeared highly resistant to using validated psychiatric measures or screening tools such as the EPDS and Patient Health Questionnaire (PHQ-9). | Infrequent based on intuition - “I am largely responsible for PHQ-9 being introduced…when it comes to my own type of practice, I very rarely get the PHQ-9 out and get people to tick boxes but I will take the questions from it and I will use those. So, umm, I would be lying if I said I used a formal structured questionnaire to get a clinical diagnosis, because I don’t” (GP1, P.19). |
Bilszta et al. (2011) [23] | None identified | N/A |
Kean et al. (2011) [34] | None identified | N/A |
McCauley and Casson (2013) [33] | None identified | N/A |
Santos et al. (2013) [36] | No evidence of screening tools used by primary healthcare professionals within the study region. | N/A |
Glasser et al. (2016) [35] | No screening tools identified within the study. However, 91.2% of family practitioners indicated they would be willing to use a brief questionnaire to identify the signs of PPD. | N/A |
Approaches to screening
Factors that influenced screening
Management of PMHPs in primary care
Pharmacological management
Available supports
Barriers to service provision
Service user
Physician
System level barriers
Discussion
Theme | Findings | Limitations of current evidence | Recommendations |
---|---|---|---|
1. Identification of PMHPsa | A lack of consistent approach to screening for perinatal depression and anxiety evident. Limited use of validated screening tools to aid identification of women experiencing psychological distress. | None of the included studies specifically explored FPsb approach to identifying perinatal psychological distress in primary practice. Studies predominantly examined and explored identification of PPDc. | Universal screening for perinatal depression and anxiety using short validated screening tools to be considered for primary care. Explore perinatal mental wellbeing at all antenatal and postnatal interactions with women and their partners. Training opportunities are required to prepare FPsb to incorporate validated screening tools into primary practice. Further research to explore current screening practices including the specific cues and observations that alert FPsb to the possibility of PMHPsa. |
2. Management of PMHPsa in Primary care | Pharmacological management of PMHPsa was identified as the main treatment modality offered to women in primary care. | The review identified studies which predominantly focused on pharmacological management and made limited reference to non-pharmacological management of PMHPsa. | FPsb require support with perinatal pharmacological treatment decisions for women experiencing PMHPsa. FPsb require access to a variety of PMHd specific treatment interventions including both pharmacological and non-pharmacological options. Further research is required to identify the non-pharmacological options available to and required by FPsb. |
Barriers to service provision | |||
3a. Service user | A reluctance of women particularly from minority ethnic and diverse cultural backgrounds to ask for help because of the perceived stigma associated with PMHPsa. | Only one study explored FPsb encounters with Black and minority ethnic women experiencing PMHd care. | National campaigns are required to increase awareness of the spectrum of PMHPsa and encourage women and their families to seek support. Stigma at an individual, public and service level needs to be addressed through awareness and availability of resources and supports. Further research to explore FPsa encounters with women from diverse ethnic and minority groups to identify support mechanisms required by FPsb. |
3b. Physician level | A lack of knowledge and skills were reported as barriers to screening and treatment of PMHPs by FPsa. | Only one study evaluated the training and education needs of FPsa in relation to PMHd. | An exploration of FPsb training and education needs in relation to PMHd would ensure that education strategies and professional development opportunities are appropriately contextualised to the needs of FPsb. |
3c. System level | A lack of available and timely access to resources, clearly defined care pathways and specialist PMHd services. | Included studies did not examine the PMHd referral support needs of FPsb. | FPsb require timely access to a range of culturally sensitive and PMHd specific services. A family approach to PMHd care has to be considered to support the woman and family as a whole. |