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Table 2 Descriptive characteristics of studies included in the review

From: Family physicians perceived role in perinatal mental health: an integrative review

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
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.