Background
Common mental disorders (CMD) such as depression and anxiety are chronic, relapsing conditions causing significant morbidity with around one in four adults being affected in one year [
1]. While pregnancy and the postnatal years may not be periods of increased prevalence they are sensitive periods, when these disorders can disrupt biological, attachment and parenting processes that subsequently affect child development and behaviour [
2,
3].
In general populations, pharmacotherapy and psychological therapies offer effective treatment for CMD, with offer and uptake of specific modalities, or multi-modal treatment, informed by disorder type, current episode severity, past history and patient preference. Treatment with pharmaceuticals is highly prevalent; studies of general (not pregnancy specific) primary-care populations indicating that 63 % of UK patients treated for anxiety and 98 % treated for incident depression receive prescriptions, and in Germany insurance data indicates pharmacotherapy outweighs psychological therapy for patients with major depression by more than 4:1 [
4‐
6]. Pharmacological treatment duration may be considerable - UK guidance recommends antidepressant treatment extends at least six months after remission of symptoms and for a minimum of two years for those at risk of relapse [
7], and reviews every 2–3 months are needed to assess the continued need for pharmacological treatment of generalised anxiety and panic disorders [
8].
Treatment may be interrupted by pregnancy, when many women discontinue pharmacotherapy [
9] for reasons that will likely centre around the perception of potential risk of harm to the foetus. The absolute and relative risks of harm are a subject of controversy, some studies have found a small increased risk of some birth defects associated with SSRI use in early pregnancy e.g. [
10], although others have not [
11]. Expectant mothers may grossly over-estimate any risks [
12], which may mis-inform the decision to discontinue. Both gradual and abrupt discontinuation from antidepressants and benzodiazepines in general populations can result in a variety of temporary distressing withdrawal symptoms, although absolute rates have proven difficult to establish, and there are few studies in pregnancy [
13‐
15]. Of greater clinical concern to the mother and her child is for potential relapse following discontinuation, although little research has been conducted and the two are not conclusively linked [
16,
17]. A general increased risk of relapse is associated with greater initial episode severity, and a higher number of previous episodes [
16,
17]. There is, however, growing evidence for the negative consequences of untreated CMD during pregnancy for the mother, her developing foetus and the child in later life [
18]. Even mild or subclinical disorder causes morbidity and can result in harmful consequences for some offspring of those affected [
19]. In the UK, guidance issued to the National Health Service (NHS) promotes access to non-pharmacological treatments for CMD during pregnancy, stepping up with disorder severity to low dose pharmacological treatment, preferably monotherapy, as needed [
20,
21]. There are few data to illustrate the extent to which the treatment gap after reduction of pharmacotherapy is filled by other therapies, including psychological treatment.
Rates of common mental disorders (CMD) in the community are higher for those who are socially and economically disadvantaged [
22]. People originating from South Asia comprise 5.3 % of the population of England and Wales and, in general, these minority ethnic groups are at higher risk for CMD because they are disproportionally disadvantaged; they may also face additional burden on their mental health due to racism or discrimination [
23‐
26]. Certain sub-groups of ethnic minorities are at higher risk of mental disorder, for example recently migrated South Asian women have around double the burden of distress compared to second or third generation migrants [
27].
The Equality Act 2010 decrees that NHS treatment and care should be equitable at point of access, including treatment for common mental disorders. The small number of studies examining CMD treatment disparities for ethnic minorities in the UK and US, however, indicate inequitable prescribing and access to talking therapies [
25,
28,
29]. One study in London found variation in the types of drugs prescribed (anxiolytics/hypnotics vs. antidepressants) by ethnicity [
30]. There are few published data describing variation in treatment, or under treatment, in the maternal period. This is important to investigate because the higher fertility rate of some minority ethnic women [
31,
32] combined with greater risk of mental disorder means that any treatment disparity or variation would have disproportionately large effects on minority ethnic communities.
The Born in Bradford (BiB) birth cohort study provides an ideal data source in which to examine potential minority ethnic inequalities in CMD treatment during pregnancy. Bradford is a city of around 500,000 inhabitants in the North of England with high levels of socio-economic deprivation and ethnic diversity. BiB was set up to examine the impact of environmental, psychological and genetic factors on maternal and child health [
33,
34]. Over 12,000 women were recruited during their pregnancy, BiB participants gave permission for their demographic, health and socio-economic data provided at recruitment to be linked with routinely collected sources of data. Previously we have used linked BiB research and primary care data to uncover ethnic disparities in the identification of CMD in primary care [
35]. In this study we aimed to examine the quantity and types of treatments offered to women who were identified with CMD before, during and up to one year postnatally, and assess if there was variation in disorders or treatment by ethnic group.
Our research questions were:
1)
To what extent is pharmacological treatment curtailed and replaced by non-pharmacological treatment during pregnancy?
2)
Do disorder and treatment offered vary by maternal ethnicity?
Discussion
Summary of findings
We analysed routinely collected primary care data from 2,234 maternal women with markers of common mental disorders living in an ethnically diverse and economically deprived city. The majority of women were discontinued from pharmacologic treatment prior to and during pregnancy but this did not appear to be balanced by an increase in access to non-drug treatment such as psychological therapies. Minority ethnic women were more likely than White British women to have a marker of diagnosis, symptoms or signs of anxiety rather than depression in their medical record. Adjusted for indication, minority ethnic women appeared to have less access to treatment both pre- and post-birth, and were less likely to be recorded as being treated with both pharmacology and non-pharmacological modalities in the postnatal year than White British women.
Strengths and limitations
This study included a large number of minority ethnic women with accurate data on gestation dates and further pregnancies. We used a broad definition of CMD to minimise recording variation in the medical record. Research data were linked to the primary care record using unique identifiers, minimising differences in quality of non-unique personal identifiers between ethnic groups. The tight geographic focus minimises potential bias due to regional variation in coding or prescribing practices which could be confounded with ethnic density in different regions. This study demonstrates the power of data linkage to address important health services research questions and identify areas for quality improvement.
Our study has several limitations. There was some overlap in women included in analyses for both time periods which may have affected our estimates. Due to small numbers we were not able to sensibly analyse the data by more precisely defined ethnic groups, which will have led to potentially substantial heterogeneity within our categorised groups. We had no access to medical records prior to six-months pre-conception which will have led to an under-estimate of treatments if referrals or prescriptions were made just before this date, or identification was noted prior to this date. Additionally, we did not have access to the contents of referral letters or free-text notes which may have led to under-estimates, or the misrepresentation of inequalities, if these data were systematically different by ethnic group. The recognition and management of CMDs by midwives or health visitors may not have been recorded in the electronic record, but because GPs should be notified of suspected CMD [
20,
21], we do not think this impacted materially on our results.
For classifying women as ‘
identified’ we did not rely on Read codes indicating diagnoses because they have only 6–26 % sensitivity for disorder [
38,
39], recording of diagnoses versus symptoms appears to change over time [
38,
40], and we were unsure whether either of these factors also varied by practice. We had no indication of illness severity, and combining symptoms and signs with diagnoses may have hampered our analysis of whether and with what ‘
identified’ women were ‘
treated’ if this varied by ethnic group. Our Read code list, while extensive, may not be exhaustive. By including Read codes for community referrals and monitoring appointments we operationalised a rather liberal definition of non-pharmacological treatment which may include women who were not in receipt of an effective treatment. Our definition of ‘
treatment’ will overestimate the number of women actually undergoing treatment because we did not know which women started, completed, or dropped out of treatment. This means actual treatment rates are lower than reported here. In line with other estimates of general and maternal primary care attendees [
39,
41,
42], treatment rates in this cohort under-represent the number in potential need with psychological distress undetected in primary care for an estimated 31–47 % of women [
35]. Because minority ethnic women are more than twice as likely to have an unrecognised disorder and therefore no NHS treatment [
35], our results are conservative and under-represent absolute disparity in service use and treatment need. Our estimates are of event coding in the medical record and not treatment uptake or success, neither are they adjusted for need, which may vary considerably between and within ethnic groups. The lack of a reliable indicator in primary care of disorder severity or amelioration meant we could not differentiate between women who were discontinued from pharmacotherapy because they no longer needed treatment, and those with active disorder requiring further support. This may have affected our findings if discontinuation by indication varied between ethnic groups.
Other factors such as education or ability in English may influence treatment sought or received, such as access to psychological therapies, but it was beyond the scope of our descriptive study with small numbers of treated women to further stratify our analyses. As with all analyses of routine general practice in the UK there are no linked data to indicate which prescriptions were filled, or which courses were completed, and we did not have diagnostic data available which would have enabled more accurate estimation of treatment inequalities. We did not have access to information about non-NHS treatments, such as private counselling, which may vary between ethnic and socio-economic group. Finally, the cohort is based in one city and results may not be generalisable to other areas, or nationally.
Treatment during pregnancy
Our study agrees with other data from the UK, Nordic countries and the Netherlands showing that most women taking antidepressants prior to or at the start of pregnancy discontinue them before delivery [
9,
43‐
45]. Our results add to this literature by demonstrating that, for most women, withdrawal from pharmacological treatment does not seem to be replaced with alternative active treatments. The implication is that a proportion of women with active anxiety or depression symptoms are simply waiting out their pregnancy without treatment. UK guidance covering the study period recommended that after withdrawal of pharmacological treatment of mild depression before or during pregnancy, doctors should monitor symptoms or consider referral for brief psychological treatment [
20]. New guidance brought in after the end of our study period recommend facilitated self-help in these cases [
21]. For those experiencing moderate or severe depressive episodes, and those with anxiety, recommendations were to switch drugs to those with a better safety profile, or switch to a psychological treatment [
20]. These recommendations are unchanged in the new guidance, with increased emphasis on the management of anxiety disorders in pregnancy, for which non-pharmacological treatment is the preferred option [
21].
Assuming all those in our sample who were treated pharmacologically had CMD, that depression accounted for 50 % of diagnoses, and that 70 % of depression cases were mild [
46], then 65 % of women had either anxiety, or a moderate to severe depressive episode that guidelines suggest should have remained on treatment. Our results indicate that only 15 % of women who discontinued were offered non-pharmacological treatment by the end of gestation, but women in active treatment at any one time will have been lower, as we could not adjust for cessation of time-limited psychological therapy, time lag between referral and uptake, or take up rate. It seems unlikely that 85 % of women discontinuing pharmacotherapy during the first trimester had ameliorated symptoms that did not require any further treatment. Rates of replacement therapy do not appear to approach the potential need and raise serious questions about increased risk of morbidity to the mother, the foetus and the family. During the study period the Improved Access to Psychological Therapy (IAPT) programme was piloted and then rolled out in England by the Department of Health with an aim of equitably treating people with CMD using evidence-based talking therapies (largely cognitive behavioural therapy but also including interpersonal and brief dynamic interpersonal psychotherapy, and counselling and couples therapy for depression) [
47,
48]. The IAPT programme aims to treat 15 % of CMD prevalent in the community, or, allowing for patient choice, 72 % of those identified in primary care [
48]. In time this programme has the potential to close this apparent treatment gap, however, demand currently outstrips provision, leading to long waiting times [
48] that might outlast the pregnancy for some. Initial analyses indicate potential disparity in uptake and outcomes [
49] and acceptability and local availability of non-pharmacological treatment as potential sources of health inequality requires further investigation, particularly in respect to cultural adaptation of interventions for South Asian women and non-English speakers [
50]. Further research into treatment decision-making in primary care is needed, including training and education gaps [
51].
Treatment inequalities
National studies utilising prescription data (without accounting for specific disorders) have found associations between increased prescribing of anxiolytics/hypnotics and antidepressants in practices based in areas of high deprivation, and some evidence for decreased prescribing in areas with greater proportions of Asian, Asian British or minority ethnic patients, and in single-handed practices [
52‐
55]. As minority ethnic women are more likely to live in areas of higher deprivation in the Bradford district, they may encounter dual inequalities linked to both cultural and geographic factors.
Our finding of potential treatment variation for minority ethnic (mostly Pakistani) women adds information about the maternal period to, and broadly concurs with, other, non-maternal, studies on minority ethnic inequalities. Our denominator only included primary care attendees with markers in their medical record that are indicative of CMD. When inequalities related to primary care detection rates are factored in, the risks of under-treatment for ethnic minorities in the community will be higher [
28,
35,
56]. While our analysis did not uncover gross prescribing differences, small numbers and a lack of precision may have hampered our analysis. In an English nationally representative study Cooper and colleagues found that, after controlling for symptom severity, White people were twice as likely to be prescribed antidepressants for CMD compared to Black people [
28]. Small numbers hampered analysis in South Asian ethnic groups and anxiolytics were not studied. Gater and colleagues in a study based in the city of Manchester found that White European women who were depressed, according to a diagnostic interview outside of the primary care setting, were twice as likely to have medical records that indicated antidepressant prescriptions (50 % vs 23 %) and four times more likely (25 % vs 6 %) to have been given psychological treatment than depressed Pakistani women [
25]. Ecological data from East London found that practices with high numbers of Asian people on their lists prescribed slightly
more antidepressants compared to anxiolytics/hypnotics [
30].
Our finding that minority ethnic women were more likely to be identified with anxiety/report anxiety symptoms than depression/depressive symptoms compared with White British women is new, but the implications difficult to interpret without more accurate diagnosis information. It could indicate a true difference in specific disorder prevalence by ethnicity in this sample. If so, because treatments for anxiety are primarily psychological, we would expect more minority ethnic women to be accessing non-pharmacological treatments, which they did not. This may indicate the under-provision of culturally adapted psychologically-based treatments. Although small numbers prevented us exploring the relationship between disorder type and specific treatments further, our results may indicate increased prescription of anxiolytics for need, which is a concern in view of the long recognised risks of tolerance and dependence. Alternatively, our finding may point to over-characterisation of minority ethnic women with anxiety rather than depression, along with potentially increased levels of inappropriate prescription of anxiolytics for depressive symptoms. There is little other evidence on specific disorder prevalence for different ethnic groups, but one study of a nationally representative sample did not detect statistically significant variation [
24]. Long standing questions over the validity of cross-cultural measurements and differential accuracy of diagnoses still hinder our understanding in this area [
57,
58]. Further research using larger samples, longitudinal data and mixed methods are needed to replicate these and other findings and unpick whether there are differences in need (i.e. severity and type of illness varies by ethnic group), variation in Read coding by patient (or provider) ethnic group, systematic differences in preference whereby certain treatments are less attractive to minority ethnic women, or whether there is variation in the type of treatments offered to women of different ethnic groups by GPs.
The dearth of research into maternal ethnic mental health disparities translates to a lack of specific advice to primary care healthcare practitioners, who identify and treat the majority of CMD cases, on how to ensure that identification and treatment choices are equitable. Even where advice is clear, the gap between best and actual practice may be large [
59]. Primary and community care staff need support, including better data, to enable them understand the impact of mental health inequalities on their patients and how to address them [
60].
Acknowledgements
BiB has been possible only because of the enthusiasm and commitment of the children and parents who participated. The authors are grateful to all the participants, health professionals and researchers who made BiB happen. We gratefully acknowledge the contribution of TPP and the TPP ResearchOne team in completing study participant matching to GP primary care records and in providing ongoing informatics support.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SLP wrote the statistical analysis plan, cleaned and analysed the data, and drafted and revised the paper. She is guarantor. KEP wrote the statistical analysis plan, and drafted and revised the paper. SG cleaned the data and revised the drafted paper. ESP wrote the statistical analysis plan, cleaned and analysed the data and revised the drafted paper. DM cleaned the data and revised the drafted paper. TAS wrote the statistical analysis plan and revised the drafted paper. JW wrote the statistical analysis plan and revised the drafted paper. All authors read and approved the final manuscript.