Perinatal Mood Disorders Research Articles

Implementing an inpatient postpartum depression screening, education, and referral program: a quality improvement initiative

Perinatal mood and anxiety disorders are common and may interfere with pregnancy, delivery, and the postpartum period. Best practice includes symptom screening, patient education, and appropriate referrals; however, many hospitals struggle to identify and support perinatal mood and anxiety disorders patients. Therefore, the Cedars-Sinai Postpartum Depression Screening, Education and Referral Program was initiated and evaluated. Using the Standards for QUality Improvement Reporting Excellence 2.0 guidelines, we reported outcomes (N=19,564 deliveries) from 4 interventions: (1) nurse-champion training; (2) use of the 9-item Patient Health Questionnaire-9 in the postpartum unit; (3) a series of brief in-service trainings; and (4) a 10-minute video training. We collected data including nurse feedback, screening rates, screen-positive rates, and social work consultation rates. The 4 interventions increased: (1) nurse-champion screening comfort and perinatal mood and anxiety disorder knowledge; (2) Patient Health Questionnaire-9 screening rates from 10% to 99% and screen-positive rates from 0.04% to 2.9%; and (3) rates of social work consultation from 1.7% to 8.4%. Quality improvement results from the first 3 years of the program suggest that 4 interventions improved screening rates, screen-positive rates, and social work consultation rates. Future work will focus on method of screening, patients at highest risk of perinatal mood and anxiety disorders, and ongoing nurse training.

Evaluating the Impact of a Novel Peer-to-Peer Educational Modality on Knowledge and Attitudes About Perinatal Mood and Anxiety Disorders.

This study assessed whether the use of a peer-to-peer educational book, written and illustrated by women who experienced common mental disorders (CMDs) in the perinatal period, can positively impact women's knowledge and attitudes about these conditions. This one-group pretest/posttest survey assessed participants' knowledge and attitudes regarding CMDs immediately before and after reading INSPIRE: Stories of Motherhood. The book is composed of women's stories and artwork about their own experiences with parenthood, with an emphasis on the challenges of parenthood and depictions of CMDs, depression and anxiety, during the peripartum period. Study participants were recruited at the Robert Wood Johnson Medical School Obstetrics and Gynecology ambulatory care office in New Brunswick, NJ and participated while waiting for their appointments. Our voluntary study population included English-speaking females over age 18. Primary outcomes measured were knowledge and attitudes about CMDs. Measures included individual Likert scale items and composite "stigma scores." 325 adult women were approached and 251 agreed to participate (response rate 77%). 181 of the participants completed all of the items in the pre- and posttest surveys. Results suggested increased knowledge and more positive attitudes after the intervention, corresponding to a decrease in stigma between the pre- and posttest surveys. The mean difference in stigma score on the 5pt Likert scale was 1.5 (95%CI .9 to 2.1, p < .0001), and on the 3pt Likert scale was 0.9 (95%CI .3 to 1.5, p = .0028). The study suggests that resources that highlight lived experiences with peripartum CMDs as told by women themselves may be a useful educational tool. In this study, the book INSPIRE: Stories of Motherhood, told and illustrated by women who have experienced CMDs, increased participants' knowledge and resulted in more positive attitudes about these disorders.

Understanding Perinatal Mood and Anxiety Disorders: A Learning Health Sciences Approach to Evaluating Underdiagnosis, Undertreatment, and Health Policy Impact

Understanding Perinatal Mood and Anxiety Disorders: A Learning Health Sciences Approach to Evaluating Underdiagnosis, Undertreatment, and Health Policy Impact

Counseling advocacy: seeking justice for black birth equity

ABSTRACT Black women and infants are up to 3.5 times more likely to die due to birth-related complications than their White and Hispanic counterparts. Research points to complex racial and social inequities, including inadequate perinatal mental health care, as primary contributors to the gap in birth outcomes. During pregnancy, untreated perinatal mood and anxiety disorders are associated with adverse birth outcomes and, therefore, contribute to increased mortality and morbidity risks for Black mothers and their infants. Cultural competency is empirically supported as a framework for reducing racial health disparities. Professional counselors are well-positioned to play a vital role in addressing perinatal mental health disparities impacting Black women. This article provides a contextual overview of the intersecting perinatal medical and mental health disparities affecting Black women and discusses implications for counselor advocacy.

The Importance of Information: Prenatal Education Surrounding Birth-Related Pelvic Floor Trauma Mitigates Symptom-Related Distress

Background: Birth-related pelvic floor trauma and its sequelae (PFTS) are associated with higher rates of perinatal mood and anxiety disorders in the fourth trimester. The fourth trimester is a critical window for long-term health outcomes, and identifying factors that buffer the impact of PFTS is an important research priority. Objectives: We hypothesized that lack of prenatal pelvic floor-focused education may be associated with greater distress following PFTS. Study Design: Hypotheses were investigated using a repeated-measures (study 1; n = 36) and cross-sectional (study 2; n = 226) design among participants reporting PFTS. Questionnaires were completed online, and included qualitative and quantitative responses. Methods: Study 1 participants completed a questionnaire within the first 8 weeks and approximately 3 months postpartum. Study 2 participants (≤5 years postpartum) completed a 1-time questionnaire. We examined associations among pelvic floor education, pelvic floor symptoms, and indices of mental health. Moderation analyses were conducted (study 2) to test whether the association between pelvic floor and mental health symptoms varied depending on level of discrepancy between postpartum expectation and experience. Results: In both studies, a high percentage of participants reported a lack of pelvic floor education, and significant associations were seen between pelvic floor and psychological symptoms. In study 2, individuals who reported high discrepancy between expectations and experience had the strongest associations between pelvic floor and psychological symptoms; for those reporting low discrepancy, the association was nonsignificant. Conclusion: Prenatal pelvic floor education is a key aspect not just in reducing risk of PFTS, but mitigating distress if it does occur.

Comparison of Delivery-Related, Early and Late Postpartum Severe Maternal Morbidity Among Individuals With Commercial Insurance in the US, 2016 to 2017

This cross-sectional study assesses the relative rates and characteristics of early and late postpartum severe maternal morbidity overall and among racial and ethnic groups and individuals with perinatal mood and anxiety disorder.

A promising new model of care for postpartum depression: A randomised controlled trial of a brief home visitation program conducted in Houston, Texas, USA.

Postpartum depression (PPD), a perinatal mood and anxiety disorder (PMAD), is a leading cause of complications of pregnancy and childbirth. In the United States, approximately 20 percent of women suffer from PMADs. In Houston, Texas, an estimation of 12,000 - 15,000 women experience PPD each year. Within the Texas Children's Paediatrics network, a large paediatric network located in Houston, Texas, mothers are screened during paediatric well-child visits and those screening positive receive a referral to a psychiatrist with the network. However, there are not enough psychiatrists to meet the demand of services and Black, Latina, and women on Medicaid during pregnancy are less likely to attend a psychiatric visit compared to White, non-Hispanic women. This study used a randomised control trial design to measure the effectiveness of an alternative treatment option for a racially diverse population of postpartum women with mild to moderate symptoms of PPD, a five-session home visitation program using the Problem-Solving Tools for PPD (PST4PPD) model delivered by master's level social workers. The control group was allocated to standard treatment with a psychiatrist. A total of 118 women gave consent and were randomised, 72 to home visiting and 46 to psychiatry. Results demonstrated that all participating mothers had significant decreases in PPD symptoms. The change in PPD symptoms among those in the home visitation program was not significantly different from the change in the control condition, indicating that the home visitation program was as effective as psychiatric treatment in significantly reducing PPD symptoms. Additionally, a high proportion of women in the home visitation program completed visits and demonstrated increased maternal self-efficacy. Based on these results, a short-term home visitation program by a social worker (PST4PPD) appears to be a promising treatment option for postpartum women with mild to moderate PPD symptoms.

Mental Health in Obstetric Patients and Providers During the COVID-19 Pandemic.

Psychiatric morbidity is the most common childbirth complication with 1 in 5 women experiencing a perinatal mood or anxiety disorder. The cost of this psychiatric morbidity is pervasive, contributing to devastating maternal health, child developmental, and economic consequences. The coronavirus disease 2019 (COVID-19) pandemic, and associated changes to perinatal experiences, resulted in profound psychological reactions including increased anxiety, depression, stress disorders, and sleep disturbance, further impacting obstetric patients. Providers’ mental health has been challenged by moral injury and shared trauma. This article reviews mental health outcomes in regard to the COVID-19 pandemic for obstetric patients and their providers.

Protecting the infant-parent relationship: special emphasis on perinatal mood and anxiety disorder screening and treatment in neonatal intensive care unit parents.

Perinatal mood and anxiety disorders (PMADs) are common, particularly among parents of infants requiring admission to the neonatal intensive care unit (NICU), yet remain underdiagnosed and undertreated. Undertreated parental mental health disorders can interfere with healthy infant development, compounding abnormal neurodevelopment and psychosocial development that preterm or ill newborns may already face. Interdisciplinary efforts to increase PMAD awareness, screening, and referral uptake may improve family-infant health and developmental outcomes in high-risk infants requiring NICU admission. Therefore, special emphasis on PMAD screening and treatment in NICU parents aligns with the American Academy of Pediatrics mission and should be a focus in neonatal care and included in education, quality improvement, and outcome-based research initiatives.

The Before Baby Relationship Checkup: A Couples-Based Intervention to Reduce Relationship Risk Factors for Perinatal Mood and Anxiety Disorders.

Relationship conflict and lack of partner support are risk factors for perinatal mood and anxiety disorders. An intervention to strengthen couples' relationships before birth may reduce relationship risk factors for perinatal mood and anxiety disorders, though no research has explored this to date. The aims of this Stage 1 open-series non-experimental proof of concept study were to adapt the 'Marriage Checkup', an evidence-based intervention for relationship distress, as a preventative intervention for perinatal mood and anxiety disorders and to assess its feasibility and acceptability. Pregnant women receiving care at a university-based obstetric practice, and their partners, were recruited. Ten couples participated in the Before Baby Relationship Checkup, a personalized relationship health service offered in the obstetric clinic. Quantitative and qualitative data gathered suggests the intervention is feasible to implement in an obstetric setting, and acceptable to perinatal couples. Specific adaptations to the Marriage Checkup for perinatal couples are warranted and further testing is needed to evaluate efficacy.

Trends In Primary Cesarean Section Rates Among Women With And Without Perinatal Mood And Anxiety Disorders.

Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0percent included a delivery by primary cesarean section, and 3.1percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

Implementation of a Screening Tool for Identification of Perinatal Anxiety and Mood Disorders in Postpartum Women

Perinatal mood and anxiety disorders (PMADs) are the most prevalent complication of childbirth; they can lead to a host of negative consequences for postpartum women and their newborns. Because these conditions are frequently overlooked, evidence-based practice supports the use of screening tools to identify women with PMAD. Implementation of the Generalized Anxiety Disorder (GAD–7) screening tool was used to increase identification of perinatal anxiety in postpartum women.

Improving access to perinatal mental health services: the value of on-site resources

Perinatal mood disorders have both short- and long-term negative consequences for mothers and their babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care. The objective of this report was to evaluate the utilization of mental health services in an urban, inner-city hospital following the implementation of colocated counseling services across 10 county-sponsored clinics that serve a medically underserved population. We further explored antecedents of a positive postpartum depression screen, factors associated with successful referral, and the rate of perinatal mood disorder diagnoses following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared with historically separated services. This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 who were compared with a historic cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was used to evaluate women at their postpartum visit, and a mental health service referral was offered to women with a score of ≥13. The primary outcome was a comparison of completed referrals between cohorts with and without colocated mental health services following a positive postpartum depression screen. Statistical analysis included chi-square tests with a P value of <.05 being considered significant and adjusted multivariate analyses for perinatal outcomes associated with a positive postpartum screen. Between January 2017 to December 2019, 25,425 women completed a postpartum depression screen with 978 (4%) of those recording a positive screen. After implementation of colocated mental health counselors, completed perinatal mental health referrals significantly increased when compared with the historic cohort without colocated services (57%; 560 of 978 vs 22%; 238 of 1106; P<.001). Adverse neonatal outcomes, such as stillbirth (adjusted risk ratio, 9.5; 95% confidence interval, 6.35-14.26) and neonatal demise (adjusted risk ratio, 14.3; 95% confidence interval, 6.67-30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen who were diagnosed with a depressive disorder in the peripartum period. There were no specific features associated with those who did or did not complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation, and the referral rate was associated with higher scores on the depression screen (P<.001). Utilization of mental health services following a positive depression screen more than doubled following the implementation of colocated services.

Advocacy, Social Justice, and Counselor Identity During the Black Lives Matter Movement

Advocacy, Social Justice, and Counselor Identity During the Black Lives Matter Movement

Implementing a Safety Bundle to Improve Screening and Care for Perinatal Mood and Anxiety Disorders

ObjectiveTo improve screening and care of individuals with perinatal mood and anxiety disorders (PMAD) through the implementation of a perinatal mental health safety bundle. DesignRapid-cycle quality improvement model using four plan–do–study–act cycles over the course of 90 days. Individuals between 28 and 32 weeks gestation and at their 6-week postpartum follow-up visit were screened and offered stage-based care for PMAD. Setting/Local ProblemAt baseline, only 15% of clients of a suburban, private-practice women’s health clinic were receiving PMAD screening with a validated tool, and the site lacked standardized PMAD care practices among health care providers. ParticipantsHealth care providers (n = 2), staff (n = 4), and eligible patients (n = 78) at a private-practice women’s health clinic. Intervention/MeasurementsA screening, brief intervention, referral, and treatment/follow-up (SBIRT) model was used to screen eligible patients, provide treatment options, and appropriately refer for follow-up to mental health services. Team engagement occurred via weekly meetings. Measurements included pre–post maternal and team engagement survey results, biweekly chart review, and run chart analysis. ResultsEffective PMAD screening and right care were achieved for 85% of eligible individuals; this included receiving screening, referral to treatment, a scheduled mental health appointment, and clinic follow-up to ensure mental health care uptake. ConclusionUse of the SBIRT model to implement a safety bundle may contribute to improved mental health outcomes for individuals receiving perinatal care in a private-practice outpatient health care setting. Education and engagement among clinicians, staff, and patients are key to successful implementation of a safety bundle.

Using a Murine Model of Psychosocial Stress in Pregnancy as a Translationally Relevant Paradigm for Psychiatric Disorders in Mothers and Infants.

The peripartum period is considered a sensitive period where adverse maternal exposures can result in long-term negative consequences for both mother and offspring, including the development of neuropsychiatric disorders. Risk factors linked to the emergence of affective dysregulation in the maternal-infant dyad have been extensively studied. Exposure to psychosocial stress during pregnancy has consistently emerged as one of the strongest predictors. Several rodent models have been created to explore this association; however, these models rely on the use of physical stressors or a limited number of psychosocial stressors presented in a repetitive fashion, which do not accurately capture the type, intensity, and frequency of stressors experienced by women. To overcome these limitations, a chronic psychosocial stress (CGS) paradigm was generated that employs various psychosocial insults of different intensity presented in an unpredictable fashion. The manuscript describes this novel CGS paradigm where pregnant female mice, from gestational day 6.5 to 17.5, are exposed to various stressors during the day and overnight. Day stressors, two per day separated by a 2 h break, range from exposure to foreign objects or predator odor to frequent changes in bedding, removal of bedding, and cage tilting. Overnight stressors include continuous light exposure, changing cage mates, or wetting bedding. We have previously shown that exposure to CGS results in the development of maternal neuroendocrine and behavioral abnormalities, including increased stress reactivity, the emergence of fragmented maternal care patterns, anhedonia, and anxiety-related behaviors, core features of women suffering from perinatal mood and anxiety disorders. This CGS model, therefore, becomes a unique tool that can be used to elucidate molecular defects underlying maternal affective dysregulation, as well as trans-placental mechanisms that impact fetal neurodevelopment and result in negative long-term behavioral consequences in the offspring.

Systematic Screening for Perinatal Mood and Anxiety Disorders to Promote Onsite Mental Health Consultations: A Quality Improvement Report.

Perinatal mood and anxiety disorders are the most common complication during pregnancy and postpartum. Screening, diagnosis, and treatment for these disorders are inhibited by limited mental health resources for patients and health care providers, lack of provider training, and time constraints. Systematic screening combined with onsite mental health consultation is an evidence-based method to increase timely diagnosis and treatment. The purpose of this quality improvement project was to promote and improve onsite mental health consultations through the implementation of a systematic screening guideline. The systematic screening guidelines included administration of the Patient Health Questionnaire-9 at the perinatal intake visit, the Edinburgh Perinatal Depression Scale between 28 and 32 weeks' gestation and again between 2 and 8 weeks postpartum. The guidelines included onsite mental health consultations for eligible women. Screening rates, attended onsite mental health consultations, and health care provider satisfaction and feedback surveys were collected over a 3-month period, before and after guideline implementation. Perinatal mood and anxiety disorder screening rates were significantly increased from 24.9% to 64.2% (P < .001) at the perinatal intake visit and in the third trimester from 0.3% to 32.8% (P < .001) with the implementation of a systematic screening guideline. Onsite mental health consultations significantly increased from 7.2% to 15.2% (P < .001). Perinatal care providers (n = 9, 100%) were satisfied with the screening guideline and reported that it added 5 minutes or less to their office visits. The implementation of a systematic perinatal mood and anxiety disorder screening guideline increased completed screenings in the perinatal period and increased the number of attended onsite mental health consultations. Systematic screening combined with onsite mental health consultation is a successful way to identify at-risk women and offer critical and convenient maternal mental health care without increasing the burden on perinatal care providers.

A systematic review of mHealth application interventions for peripartum mood disorders: trends and evidence in academia and industry.

In this review, we aim to summarize research findings and marketplace apps for women with perinatal mood disorders with the goal of informing clinicians and patients about current risks and benefits, as well as proposing clinical implementation advice and a harmonized agenda for both academic and industry advancement in this space. Multiple searches were run of academic databases in 2018–2020, examining literature on mobile apps for peripartum mental health. Multiple searches were also run of the iOS and Android app stores in 2019 and 2020, looking at apps for peripartum mental health. Results were compared within the academic dataset as well within the commercial app dataset; the two datasets were also examined for overlap. The academic search results were notable for small sample sizes and heterogeneous endpoints. The app store search results were notable for apps of generally poor quality (as assessed by a modified Silberg scale). Very few of the mHealth interventions studied in the academic literature were available in the app store; very few of the apps from the commercial stores were supported by academic literature. The disconnect between academically developed apps and commercially available apps highlights the need for better collaboration between academia and industry. More collaboration between the two approaches may benefit both app developers and patients in this demographic moving forwards. Additionally, we present a set of practice guidelines for mHealth in perinatal psychiatry based on the trends identified in this review.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00737-021-01138-z.

Leveraging Digital Technology in Conducting Longitudinal Research on Mental Health in Pregnancy: Longitudinal Panel Survey Study

BackgroundCollecting longitudinal data during and shortly after pregnancy is difficult, as pregnant women often avoid studies with repeated surveys. In contrast, pregnant women interact with certain websites at multiple stages throughout pregnancy and the postpartum period. This digital connection presents the opportunity to use a website as a way to recruit and enroll pregnant women into a panel study and collect valuable longitudinal data for research. These data can then be used to learn new scientific insights and improve health care.ObjectiveThe objective of this paper is to describe the approaches applied and lessons learned from designing and conducting an online panel for health care research, specifically perinatal mood disorders. Our panel design and approach aimed to recruit a large sample (N=1200) of pregnant women representative of the US population and to minimize attrition over time.MethodsWe designed an online panel to enroll participants from the pregnancy and parenting website BabyCenter. We enrolled women into the panel from weeks 4 to 10 of pregnancy (Panel 1) or from weeks 28 to 33 of pregnancy (Panel 2) and administered repeated psychometric assessments from enrollment through 3 months postpartum. We employed a combination of adaptive digital strategies to recruit, communicate with, and build trust with participants to minimize attrition over time. We were transparent at baseline about expectations, used monetary and information-based incentives, and sent personalized reminders to reduce attrition. The approach was participant-centric and leveraged many aspects of flexibility that digital methods afford.ResultsWe recruited 1179 pregnant women—our target was 1200—during a 26-day period between August 25 and September 19, 2016. Our strategy to recruit participants using adaptive sampling tactics resulted in a large panel that was similar to the US population of pregnant women. Attrition was on par with existing longitudinal observational studies in pregnant populations, and 79.2% (934/1179) of our panel completed another survey after enrollment. There were 736 out of 1179 (62.4%) women who completed at least one assessment in both the prenatal and postnatal periods, and 709 out of 1179 (60.1%) women who completed the final assessment. To validate the data, we compared participation rates and factors of perinatal mood disorders ascertained from this study with prior research, suggesting reliability of our approach.ConclusionsA suitably designed online panel created in partnership with a digital media source that reaches the target audience is a means to leverage a conveniently sized and viable sample for scientific research. Our key lessons learned are as follows: sampling tactics may need to be adjusted to enroll a representative sample, attrition can be reduced by adapting to participants’ needs, and study engagement can be boosted by personalizing interactions with the flexibility afforded by digital technologies.

Parenting Interventions and Secondary Outcomes Related to Maternal Mental Health: A Systematic Review.

Perinatal mood and anxiety disorders can have far reaching negative impact on both maternal mental health and child growth and development. Multimodal group parenting programs have been shown to improve maternal mental health symptoms however, they are often costly to provide and not accessible to many mothers, especially those mothers suffering from mental health symptoms. Therefore, the authors sought to answer the following question by undertaking a systematic review of the literature: are parenting interventions aimed at improving maternal-child interaction also a way to address mental health symptoms (i.e. depression, anxiety, stress) in mothers? The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. An online platform that supports the systematic review process and quality assessment according to Cochrane guidelines, Covidence, was used in conjunction with an adapted extraction tool to identify relevant studies and extract data for analysis. 11 articles were included in the qualitative synthesis. There was great heterogeneity between study interventions and measurement of outcomes for maternal mental health symptoms which precluded meta-analysis. Studies reviewed did not demonstrate consistent evidence to recommend that parenting interventions leads to improvement in maternal mental health symptoms for depression, anxiety or stress. However, there was evidence that participating in parenting programs does not worsen these symptoms and some encouraging evidence that alternative delivery methods, beyond face to face, could, with more research, lead to more financially feasible and sustainable models of delivery of these types of interventions in the future.