Results of a Statewide Survey of Obstetric Clinician Depression Practices

Abstract

Purpose:

Perinatal depression affects upwards of one in seven women and is associated with significant negative maternal and child consequences. Despite this, it remains under-detected and under-treated. We sought to identify clinician practices, self-efficacy, and remaining barriers to comprehensively addressing perinatal depression care.

Materials and Methods:

Surveys were administered to obstetric clinicians in Massachusetts that queried frequency of depression screening and Likert questions about subsequent depression management.

Results:

Approximately 79.0% of clinicians approached completed the survey. Whereas most clinicians (93.5%) screened for perinatal depression at 6 weeks postpartum, fewer clinicians (66.1%) screened during pregnancy. Most reported they were comfortable providing support to their patients (98.4%), but fewer endorsed being able to treat them on their own (43.0%). Most noted an ability to treat with antidepressants (77.9%); however, fewer endorsed adequate access to nonmedication treatment (45.5%).

Conclusions:

The majority of surveyed clinicians screen for depression consistent with guidelines. However, efforts are focused on the postpartum period, despite literature citing two-thirds of patients experiencing onset before or during pregnancy. Respondents indicated an ability to treat with medication management, while noting greater challenge with referral. These findings describe the challenges of interdisciplinary coordination as a barrier to comprehensive perinatal mental health care. Clinical Trial Registration Number: NCT02760004.

Introduction

Perinatal depression is an episode of major or minor depression occurring during or in the first 12 months after pregnancy.¹ Despite affecting upwards of one in seven women and having significant negative maternal, obstetric, child, and familial consequences, perinatal depression remains under-detected and under-treated.² To address this, major organizations including the U.S. Preventative Services Task Force, the American College of Obstetricians and Gynecologists (ACOG), and the Council on Patient Safety in Women's Health Care have recommended screening in the context of systems ensuring appropriate diagnosis, treatment, referral, and follow-up.^1,3,4 Furthermore, ACOG has recommended that obstetric clinicians be prepared to manage such perinatal depression with initiation of medical therapy and/or referral to mental health resources.¹ Without needed systems in place, <20% of women who screen positive for perinatal depression will initiate mental health care on their own.²

Owing to regular contact with perinatal individuals during and after pregnancy, obstetric care clinicians are ideal for screening and managing perinatal depression.⁵ However, despite recognition of their responsibilities in addressing perinatal depression,^6
–8 obstetric clinicians (physicians, midwives, and nurses) often find it challenging because of lack of knowledge and difficult systematic referral processes.^9

–14 Limited clinician time and concerns about reluctance of patients to follow-up can also be barriers to screening and treating.^{6,9

–17} Even with well-supported universal screening programs, provider documentation of depression scores has been shown in just 35%–40% of visits.^5,18 Furthermore, limited access to treatment and referrals act as persistent barriers to comprehensive perinatal mental health screening by obstetric clinicians in many areas.⁵

To facilitate addressing depression in obstetric settings, in 2014, Massachusetts implemented the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms to increase the capacity of obstetric clinicians to address perinatal mental health and substance use disorders. The program increases the capacity of frontline clinicians to address the mental health of perinatal individuals through trainings and toolkits, access to real-time perinatal psychiatric consultation through phone and face-to-face evaluations, and linkages with community-based behavioral health resources (i.e., therapy and support groups).^19
–21 Since its inception, MCPAP for Moms has enrolled 160 (77%) Massachusetts' obstetric practices, covering >85% of the state's deliveries, and provided consultation, resources, and referrals for >9,700 patients for <$1 per perinatal woman per month.^19,20

Given clear recommendations from governmental and professional organizations, evolving standards of care for obstetric clinicians, and access to a statewide perinatal psychiatry access program, understanding current practices and challenges to further progress is imperative. We conducted this survey to understand obstetric clinician attitudes and practices and to identify sustained barriers to comprehensively addressing perinatal depression care.

Materials and Methods

Licensed obstetric clinicians (physicians, nurse midwives, and nurse practitioners) at 10 Massachusetts obstetric practices enrolled in the study described hereunder were approached to complete this survey between November 2016 and June 2019. Clinicians answered survey questions that quantified their demographic characteristics, including training, practice site, and role. The survey included (1) time points during which the clinician participants screened for depression in their obstetric patients and (2) Likert-scale questions querying about practice environment, depression management self-efficacy, adequate care access, and ability to ensure timely treatment.

This survey was part of the run-in phase of a cluster randomized controlled trial (RCT), the Program In Support of Moms (PRISM), where after collection of baseline surveys, practices were randomized to an intervention group that received local champions, depression care registries, trainings, and workflow consultation.^22,23 Both intervention and standard of care groups had access to the MCPAP for Moms program, described previously.

Twenty-three obstetric practices in Massachusetts were approached for participation in the RCT; 14 consented and 10 met study requirements. Clinicians from the 10 sites are included in this analysis. The data constitutes baseline information, some of which was utilized in the randomization schema.²⁴ As the RCT is ongoing, the sites remain blinded at the time of this report. This study had human-subjects committee approval by affiliated Institutional Review Boards (IRBs) of all participating sites.²⁴

Results

A total of 124 of 157 providers (79.0%) approached completed the survey. The number of clinician participants in each of the 10 practices ranged from 4 to 28 clinicians (mode of 6). Four of 10 practices were within academic settings, with 2 of these practices training resident physicians, who also completed the survey. The remaining six practices were community practices. Resident physicians comprised 37.7% of clinicians surveyed, ranging from their first to fourth year of training.

Obstetric clinicians reported screening for perinatal depression with a validated screening tool throughout pregnancy (first [59.7%], second [18.5%], and third [33.1%] trimesters), and the postpartum period, with the majority screening at the 6-week postpartum visit. Clinicians screened women for depression an average of 2.3 times in the perinatal period. Six clinicians did not screen their patients at all, whereas 18.5% screened their patient just once. Of those who only screened once, all of them screened at the 6-week postpartum visit. One third of respondents did not screen during pregnancy, whereas only 6.4% did not screen during the postpartum period. The majority of clinicians reported documenting screening results in the medical record (Table 1).

Table 1.

Managing Perinatal Depression in Obstetric Settings: Assessment of Clinician-Level Perinatal Depression Screening and Management by Obstetric Clinicians

	n	Likert choice, n (%)			N/A
	n	Strongly disagree and disagree	Neutral	Strongly agree and agree	N/A
Screening
I consistently screen at the set time points	123	12 (9.8)	0 (0.0)	110 (89.4)	1
I document the diagnosis of depression in obstetric patients' charts	123	4 (3.3)	1 (0.8)	118 (95.9)	0
Treatment (general)
I can effectively treat my depressed patients myself	121	59 (48.8)	10 (8.3)	52 (43.0)	0
I discuss depression and depression treatment options with my obstetric patients	123	8 (6.5)	2 (1.6)	112 (91.1)	1
I provide my obstetric patients reassurance and support regarding depression	124	0 (0.0)	1 (0.8)	122 (98.4)	1
I am usually able to meet the needs of my obstetric patients with depression	123	24 (19.5)	10 (8.1)	87 (70.7)	2
Treatment (pharmacotherapy)
I discuss the risks and benefits of antidepressant use during pregnancy and lactation	124	10 (8.1)	3 (2.4)	110 (88.7)	1
I start my obstetric patients on antidepressant medications when indicated	122	20 (16.4)	3 (2.5)	95 (77.9)	4
When a patient is prescribed an antidepressant, I follow up by monitoring their depression severity	123	10 (8.1)	7 (5.7)	103 (83.7)	3
I monitor my obstetric patients' depression and adjust medications as indicated	120	33 (27.5)	10 (8.3)	73 (60.8)	4
Treatment (referral)
When my patient's obstetric care is complete, I am able to transition postpartum women for ongoing mental health follow-up	121	25 (20.7)	6 (5.0)	88 (72.7)	2
When I need a psychiatric consultation, I am able to receive it in a timely manner	120	40 (33.3)	6 (5.0)	67 (55.8)	7
I am able to ensure that my depressed obstetric patients receive treatment for depression in a timely manner	124	31 (25.0)	8 (6.5)	79 (63.7)	6
I have adequate access to non-medication treatment for my obstetric patients with depression or other mental health concerns	121	50 (41.3)	10 (8.3)	55 (45.5)	6

Most clinicians agreed or strongly agreed that they were comfortable discussing treatment options for and providing support to their obstetric patients with depression. However, fewer agreed or strongly agreed that they could meet the needs of or treat their depressed patients on their own. Regarding pharmacotherapy, the majority of clinicians agreed/strongly agreed that they discussed the risks and benefits, initiated medication treatment, and monitored depression severity while on antidepressants, whereas just over half adjusted medications. When queried about referral, most clinicians agreed/strongly agreed that they were able to refer patients to mental health follow-up, but fewer agreed/strongly agreed that they could ensure psychiatric consultation in a timely manner, less than half agreed/strongly agreed that they had adequate access to nonmedication treatment, like psychotherapy (Table 1).

Regarding practice-level approaches to perinatal depression care, less than half of clinicians agreed/strongly agreed that there was an individual in their practice responsible for tracking positive screens. A smaller majority agreed/strongly agreed that there was a standard process for directing patients to mental health resources in the community (Table 2).

Table 2.

Managing Perinatal Depression in Obstetric Settings: Assessment of Practice-Level Perinatal Depression Management by Obstetric Clinicians

	n	Likert choice, n (%)			N/A
	n	Strongly disagree and disagree	Neutral	Strongly agree and agree	N/A
Standard practices
Someone in my practice tracks patients who screen positive for depression	119	50 (42.0)	4 (3.4)	58 (48.7)	7
This practice has a standard process for directing patients to appropriate mental health resources in the community	123	26 (21.1)	20 (16.3)	73 (59.3)	0
The leadership in this practice creates an environment that supports practice change efforts	123	9 (7.3)	14 (11.4)	99 (80.5)	0
This practice always learns from its mistakes	121	22 (18.2)	34 (28.1)	64 (52.9)	0
Time
I have enough time to get everything done at work	124	67 (54.0)	27 (21.8)	29 (23.4)	0
The practice leadership and environment make sure that we have the time and space necessary to discuss changes to improve care	122	21 (17.2)	21 (17.2)	79 (64.8)	0
This practice operates at a high level of efficiency	123	34 (27.6)	31 (25.2)	57 (46.3)	0
Staff
Support staff at this practice/clinic have the knowledge and skills they need to detect and address depression	124	30 (24.2)	29 (23.4)	64 (51.6)	0
Staff members in this practice operate as a team	124	3 (2.4)	10 (8.1)	111 (89.5)	0
Staff members are trained and encouraged to work to their highest capacity	124	23 (18.5)	22 (17.7)	78 (62.9)	0

The majority of clinicians described their practice environments as either hectic or quite busy, which aligned with only a minority of respondents agreeing that they had enough time to get everything done at work. Of note, two-thirds agreed/strongly agreed that their practice staff members are trained and encouraged to work at their highest capacity, whereas approximately half thought the support staff in the practice had the knowledge and skills they needed to detect and address depression (Table 2).

Discussion

Perinatal depression is one of the most common complications of pregnancy and a preventable cause of maternal mortality and morbidity.^{1,2,25

–37} As such, it is recommended that clinicians screen perinatal individuals with validated tools and do so in the context of systems facilitating engagement with assessment, treatment, and/or referral as needed.^1,3 Our survey results reveal that the majority of clinicians are screening in the postpartum period and, as recommended by ACOG, are able to discuss and initiate pharmacotherapy when appropriate. However, they also recognize their inability to manage perinatal depression on their own and experience challenges with timely access to mental health specialists and first-line psychotherapy treatment.

As per ACOG guidelines, the majority of Massachusetts obstetric clinicians surveyed screened at least once during the perinatal period.³⁸ Less than half of clinicians reported screening during pregnancy, despite literature citing approximately two-thirds of patients with depression onset predating or occurring during pregnancy. Clinician efforts are heavily focused on screening in the postpartum period, despite research indicating that only 40% have postpartum onset.³⁹ The importance of screening multiple times during the perinatal period is underscored by the fact that ∼15% of women in the United States receive inadequate prenatal care.⁴⁰ Furthermore, it has previously been reported that ∼40% of women do not see their obstetric clinician in the postpartum period.⁴¹

Our findings are consistent with previous study findings, which have shown that obstetric clinicians perceive a lack of referral networks,^9

–12,14 inadequate capacity, and insufficient resources to ensure depression evaluation, treatment, follow-up, and care coordination.^{5,9

–12,14,42} In our study, the majority of clinicians agreed/strongly agreed that they initiate and manage the components of care that they can execute independently (e.g., discussing the risks/benefits of pharmacotherapy, initiating pharmacotherapy, and monitoring depression severity after prescribing). In contrast, they did not agree that they could manage components of care that require coordination beyond the clinician themselves (e.g., ensuring a psychiatric consultation in a timely manner and having adequate access to nonmedication treatment like therapy). These findings suggest that activities that obstetric clinicians can complete autonomously are being accomplished. However, when referral or engagement with a psychiatric specialist is indicated, clinicians have less agreement that this can be accomplished easily and in a timely manner. This implies that there are barriers to developing robust and responsive referral networks.

It should be acknowledged that although recommendations for obstetric clinicians to address perinatal mental health are needed^3,38 and exist, they add to the existing and increasing requirements placed on obstetric clinicians. For example, the majority of clinicians noted inadequate time to complete their work, and survey questions including the words “timely manner” had some of the greatest proportions of disagreement.

Given the mounting responsibilities and time constraints reported by obstetric clinicians, integrated or co-located mental health care could represent needed and alternative delivery models for addressing perinatal mental health. It has been shown that perinatal individuals struggle with coordination of care between multiple locations, and that patients would prefer to be treated within the obstetric practice versus the mental health setting.⁴³ It is well-established that integrated care, such as stepped and collaborative care models and medical homes, effectively integrate depression treatment into primary care settings and improve quality of mental health care and depression outcomes.⁴⁴ Such approaches have been introduced and evaluated in obstetric settings to a limited extent.^45

–48 Perinatal Psychiatry Access Programs, like MCPAP for Moms, are increasingly prevalent and currently mostly work outside the reimbursement system.⁴⁹ This helps address the need and gaps in care yet can make sustainability challenging.

It is important to consider that the results of this survey may not be reflective of all practices outside of those queried. Massachusetts is a unique state because it has a greater concentration of obstetrician/gynecologists (5.62/10,000 reproductive age women vs. 4.47 nationally),⁵⁰ psychiatrists (3/10,000 individuals vs. 1.3 nationally),⁵¹ and licensed psychologists (5.7/10,000 individuals vs. 3.1 nationally).⁵² Furthermore, MCPAP for Moms, a program designed with the mission to increase the capacity of obstetric clinicians to address maternal mental health and substance use disorders, has been available since 2014 to support Massachusetts obstetric clinicians in addressing perinatal mental health.^19,22 Any clinician caring for perinatal persons in the state of Massachusetts can voluntarily and without cost, enroll in and use the program. The program is insurance agnostic and serves all the clinicians caring for perinatal individuals.⁴⁹ MCPAP for Moms has inspired federal legislation that resulted in seven other U.S. states receiving Health Resources and Services Administration funding to establish similar perinatal access programs,⁵³ and other states and health care system developing similar programs through alternate funding mechanisms.⁵⁴ As a result, these findings may not reflect national trends, and, despite identified challenges, may in fact be optimistic of obstetric clinicians' experiences in addressing perinatal mental health.

This analysis includes baseline data from an ongoing cluster-RCT. Its continuing status limits our ability to examine what if any differences exist in practices randomly assigned to receive PRISM (MCPAP for Moms plus practice level interventions) versus MCPAP for Moms alone. The small size of several respondent groups leaves us unable to further analyze obstetric clinician demographics as it relates to survey responses at this time. Future studies should include a larger sample to elucidate whether provider type, practice size, experience, and other demographics may correlate with survey response. Future research should also explore differences in clinician knowledge, attitudes, and beliefs in areas that do and do not have these access programs, or before and after the existence of these programs. With an increasing number of access programs, there is also opportunity to evaluate which programmatic approaches are most effective in breaking down barriers.

Conclusions

The majority of surveyed clinicians screen for depression consistent with guidelines. However, efforts are focused on the postpartum period, despite literature citing two-thirds of patients experiencing onset before or during pregnancy. Respondents indicated an ability to treat with medication management while noting greater challenge with referral. These findings describe the challenges of interdisciplinary coordination as a barrier to comprehensive perinatal mental health care.

Statement of Ethics

The University of Massachusetts Medical School Committee for the Protection of Human Subjects in Research (FWA No. 00004009) approved this study (ID No. H00009163), providing review for the two UMass Memorial Health Care-affiliated practices and one practice without an IRB. In addition, six IRBs, affiliated with the seven other participating practices, reviewed the study. Of these, four ceded review to UMass and two retained independent review and approval. Participation was voluntary, and clinicians provided informed consent before completing the survey.

Footnotes

Authors' Contributions

T.M.S., J.A., and N.B. conceived of the study, made substantial contributions to conception and design of the study, and drafted the article. E.S.B., S.C., L.B., P.S., A.K.D., and N.S. have made substantial contributions to the conception, design, and execution of the study. E.S.B. and T.M.S. has made a substantial contribution to the drafting of the article. All authors have been involved in reviewing the article critically for important intellectual content, for revising and editing, and have given final approval of the version to be published.

Author Disclosure Statement

N.B. is the founding and current Medical Director of the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms) and receives salary support from the Massachusetts Department of Mental Health for that role. N.B. is the Executive Director of Lifeline4Moms that receives support from Perigee Foundation to network Perinatal Psychiatry Access Programs across the United States. N.B. is a member of the American College of Obstetricians and Gynecologists' Expert Work Group on Maternal Mental Health. N.B. has served as a consultant for Sage Therapeutics or their agents. She has also received speaking honoraria for Sage Therapeutics and has served on Advisory Boards. N.B. has served on an Advisory Board for Jannsen. N.B. has served as a consultant to Ovia Health and has received honoraria from Miller Medical Communications and WebMD/Medscape. T.M.S. receives a stipend from the Massachusetts Department of Mental Health via Beacon for her role as Engagement Director of the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms). T.M.S. is medical director of Lifeline4Moms that receives support from Perigee Foundation to network Perinatal Psychiatry Access Programs across the United States. T.M.S. co-chairs the American College of Obstetricians and Gynecologists' Expert Work Group on Maternal Mental Health and was a member of the Council on Patient Safety in Women's Health Care's task force for creation of the maternal mental health patient safety bundle and co-author on the associated commentary. T.M.S. has served on ad hoc Physician Advisory Boards for Sage Therapeutics, has received speaking honoraria, and served as a consultant on observational studies and a systematic review. T.M.S. served as a consultant to Ovia Health, and has received speaking honoraria from Miller Medical Communications. A.K.D. is supported by a Department of Veterans Affairs, Veterans Health Administration, VISN 1 Career Development Award for projects related to perinatal mental health. For the remaining authors no competing interests were declared.

Funding Information

This work was primarily supported by the Centers for Disease Control and Prevention (CDC) through a Cooperative Agreement (Grant No.: 1U01DP006093) awarded to the Principal Investigators (N.B., T.M.S., and J.A.) at the University of Massachusetts Medical School. Additional support was provided from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), (Grant Nos. KL2TR000160, UL1-TR001453, UL1-TR000161).

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