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Table 5 Excerpts from original studies

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

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.