Journal of Psychosomatic Obstetrics & Gynecology

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Strategies for improving perinatal depression

treatment in North American outpatient obstetric
settings

Nancy Byatt, Tiffany A. Moore Simas, Rebecca S. Lundquist, Julia V. Johnson

& Douglas M. Ziedonis

To cite this article: Nancy Byatt, Tiffany A. Moore Simas, Rebecca S. Lundquist, Julia V. Johnson
& Douglas M. Ziedonis (2012) Strategies for improving perinatal depression treatment in North
American outpatient obstetric settings, Journal of Psychosomatic Obstetrics & Gynecology,
33:4, 143-161, DOI: 10.3109/0167482X.2012.728649

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Journal of Psychosomatic Obstetrics & Gynecology, 2012; 33(4): 143–161
© 2012 Informa UK, Ltd.
ISSN 0167-482X print/ISSN 1743-8942 online
DOI: 10.3109/0167482X.2012.728649

 trategies for improving perinatal depression treatment in

S
North American outpatient obstetric settings

Nancy Byatt1, Tiffany A. Moore Simas2, Rebecca S. Lundquist3, Julia V. Johnson4 & Douglas M. Ziedonis3
1
Department of Psychiatry and Ob/Gyn, 2Department of Ob/Gyn and Pediatrics, 3Department of Psychiatry, and 4Department
of Ob/Gyn, UMass Medical School, Worcester, MA, USA

and other substances [6]. Postpartum depression is associated

Objective: To identify core barriers and facilitators to addressing
perinatal depression and review clinical, programmatic,
and system level interventions that may optimize perinatal
depression treatment. Method: Eighty-four MEDLINE/PubMed
searches were conducted using the terms perinatal depression,
postpartum depression, antenatal depression, and prenatal
depression in association with 21 other terms. Of 7768 papers
yielded in the search, we identified 49 papers on barriers and
facilitators, and 17 papers on interventions in obstetric settings
aimed to engage women and/or providers in treatment. Results:
Barriers include stigma, lack of obstetric provider training, lack
of resources and limited access to mental health treatment.
Facilitators include validating and empowering women during
interactions with health care providers, obstetric provider and
staff training, standardized screening and referral processes,
and improved mental health resources. Conclusion: Specific
clinical, program, and system level changes are recommended
to help change the culture of obstetric care settings to optimize
depression treatment.
Keywords:  Depression, facilitators, perinatal, postpartum,
pregnancy
Introduction
Perinatal depression can cause significant suffering for
mother, fetus/child and family [1–7]. In spite of the nega-
tive impact, barriers to the treatment of perinatal depression
persist [8–13]. Up to 18.4% of women suffer from depression
during pregnancy, and as many as 19.2% of mothers develop
a depressive disorder [14]. Untreated depression during preg-
nancy is associated with poor birth outcomes and long-term
effects on the mother, child, and family. Depressed pregnant
women are more likely to have poor weight gain and engage
in poor health behaviors including abuse of alcohol, tobacco
with offspring attachment insecurity [7], and difficult infant
and childhood temperament [2,7]; long-term consequences
include developmental delay, impaired language development
[3,4] and depressive, anxiety or disruptive disorders [5]. These
negative impacts can be mitigated by effective treatment of
maternal illness [15]. In extreme cases, perinatal psychiatric
illness can be fatal and lead to the tragic consequences of
suicide [1] and infanticide [16]. In some regions in Canada,
untreated maternal depression has been estimated to cost
over $20,000,000 annually [17].
Perinatal depression refers to minor or major episodes of
depression occurring during pregnancy and the first twelve
months postpartum [14,18,19]. In spite of profound nega-
tive effects on mother and child that are mitigated by effec-
tive treatment of maternal illness [15], perinatal depression
remains under-diagnosed and under-treated in obstetric set-
tings [20–26]. Due to regular contact with obstetric providers
and women’s preference [27,28], the obstetric setting seems
an ideal place to detect and manage depression. Programs
that integrate depression and primary care through screening,
patient education, feedback, and case management improve
outcomes in primary care settings [29]. Recognizing this,
the American College of Obstetricians and Gynecologists
(ACOG) [30,31] and others [18,32–35] advocate that obstetri-
cians screen for psychosocial stressors and depression every
trimester and provide resources and referrals when indicated.
Screening improves detection of perinatal depressive
symptoms [36], yet does not improve treatment entry [37–39]
or outcome [38,39]. Screening is intended to capture women
at increased likelihood of experiencing perinatal depression.
A positive screen indicates the need for an assessment by
a qualified provider to confirm or exclude a diagnosis of
depression [40] and determine if treatment is indicated.
Despite high acceptance of depression screening among

Correspondence:  Dr Nancy Byatt, DO, MBA, UMass Medical School, Psychiatry and Ob/Gyn, 55 Lake Ave North, Worcester, MA 01655, USA.
E-mail: nancy.byatt@umassmemorial.org

143
144  N. Byatt et al.
women, many are not amenable to additional contact with a
mental health provider [22,27,41,42]. Studies [22,27,41,42]
indicate that less than 30% of women who screen positive
for depression attend an initial or subsequent mental health
visit with some studies indicating rates as low as 6 [27] and
0% [42]. This lack of treatment engagement may be due to
under-involved providers and staff [43] and limited resources
to ensure accurate depression diagnosis, treatment, and
follow-up [33]. Screening for perinatal depression is feasible
[44,45] and increases detection and treatment rates [46–48]
when coupled with systematic changes to ensure women
receive appropriate care [44–48]. This suggests that clinical,
programmatic, and system-level changes are needed to
optimize perinatal depression treatment. An integrated
approach could overcome such barriers to addressing
perinatal depression in obstetric settings, and thus is the focus
of this paper.
The purpose of this article is to: (1) identify core barriers
and facilitators to addressing perinatal depression; (2) review
clinical, programmatic, and system level interventions that
may optimize perinatal depression treatment in obstetric
settings, and; (3) propose specific strategies and innovative
program models for addressing perinatal depression in the
outpatient obstetric setting.
Methods
We conducted a literature search in the English-language
literature indexed on MEDLINE/PubMed for the period
between 1966 and 2012. We searched using the terms perina-
tal depression, postpartum depression, antenatal depression,
and prenatal depression, matching each with the following 21
terms: treatment, barriers, facilitators, integrated, obstetric,
physician, provider, training, attitudes, access, collaborative
care, stepped care, co-located, consultation, motivational
interviewing, motivational enhancement intervention, orga-
nizational change, program, performance improvement,
policy, and service delivery. All articles were cross-referenced,
to identify other relevant articles not identified in the ini-
tial search. Abstracts of all papers identified were reviewed.
Original studies, including pilot, qualitative and clinical trials
were included. Abstract exclusion criteria were the following:
not perinatal depression related, no discussion of barriers and/
or facilitators to perinatal depression treatment, and no dis-
cussion of interventions in obstetric settings aimed to engage
women and/or providers in treatment. Full-text articles were
reviewed to ensure compliance with inclusion and exclusion
criteria. Articles that explored barriers and facilitators to peri-
natal depression were categorized by specifically identified
barriers or facilitators. Interventional articles were classified
as those providing clinical level versus programmatic versus
systematic interventions.
Results
Systematic searches yielded an initial identification of 7768
papers, many of which were duplicates. We identified 49 papers
relating to barriers and facilitators and 1, 13 and 3 papers
Journal of Psychosomatic Obstetrics & Gynecology
relating to clinical, program and systems levels interventions,
respectively that met study inclusion and exclusion criteria.
Barriers
Patient level barriers
As summarized in Table II, a variety of factors contribute to
women’s reluctance to seek and engage in depression treat-
ment during the perinatal period [10,11,13]. As demonstrated
in Table I, the available data is limited because the majority
[9–13,49–59], yet not all [8,9,60–68] of the studies are qualita-
tive and therefore not generalizable. Despite these limitations,
these data provide insight into barriers to treatment and can
inform the development and testing of interventions.
Some women report they experience the discussion of
depression treatment options to be a burdensome task that
negatively impact their own and others’ perception of them-
selves as mothers [10,13,49,57–59,65]. In addition, due to
concerns regarding medication use in pregnancy, women
worry about pharmacologic treatment options for depres-
sion [9,63,66]. Some fear losing parental rights for disclos-
ing depression symptoms [12,13,49,53,58,64]. Other women
believe that psychiatric symptoms are an expected part of
adjustment to motherhood [10,13,62,63].
Despite regular and routine contact in pregnancy, some
women report that their obstetrician does not address their
emotional needs and that they perceive their provider as unre-
sponsive or unsupportive [8,12,59,69,70]. Women also report
that their psychiatric symptoms are normalized, dismissed
as self-limited, or given cursory attention by their obstetric
provider [10,12,13,58,59,63,69–71].
Provider level barriers among obstetric providers and staff
The majority of obstetricians [72,73] midwives [74], and
nurses [74] report they have a responsibility to recognize
maternal depression. Unfortunately, this does not result in
delivery of care [73] because many factors influence whether
depression will be addressed [73]. Lack of knowledge and
skills, identification as a specialist [66,75–78], and the
absence of a systematic referral process [77,79] discour-
age the integration of depression and obstetric care. These
factors have led some to the misperception that address-
ing depression is beyond the scope of what can be offered
in an obstetric setting. Obstetric providers and staff report
multiple barriers to treating perinatal depression including
lack of time, limited knowledge of available resources, and
perceived reluctance of their patients to engage in depression
treatment [49,66,73,75–82]. The majority of obstetricians
[73,83–86], midwives [74,87], and nurses [74] report inad-
equate or barely adequate training with regards to depression
and/or mental health. Untrained obstetric providers and staff
are less likely to screen for [66] and/or discuss mental health
concerns [66,75–78,87].
Even in well-supported ‘universal screening’ programs
with algorithmic decision support and direct interconnected-
ness with psychiatry, EPDS scores are only documented in
39% of visits, and documentation of provider counseling in
35% of visits [88]. Most obstetricians report being support-
ive of screening and deem it to be effective [66], yet prefer

Table I.  Summary of studies examining barriers and facilitators.
Study/sample size
Patient level barriers and facilitators
Reay et al (2011) [61]. (n = 199) Australia
Bennet et al (2009) [8]. (n = 225) United States
Jesse et al (2010) [51]. (n = 21)
Wood et al (1997) [70]. (n = 11)
Edge et al (2004) [55]. (n = 301)
Edge et al (2008) [52]. (n = 12)
Edge et al (2010) [50]. (n = 12)
Edge et al (2011) [69]. (n = 42)
Nahas et al (1999) [54]. (n = 45)
Shakespeare et al (2003) [56].
(n = 39)
© 2012 Informa UK, Ltd.
Strategies for improving perinatal depression treatment  145
Country Setting Population of women served Study design and methods
Two public and one Women antenatal through 2 years Descriptive study: women
private hospital postpartum who screened positive for
depression (n = 98) and
a random sample who
screened negative (n = 101)
participated in survey at 2
years postpartum. Measures
included: mood, treatment
access, quality of relationship
with partner, coping, and
mother-infant bonding.
Faculty outpatient Women receiving obstetric Qualitative study: used
gynecologic practice and care semi-structured interviews to
resident obstetric practice assess intention to seek help
at large academic medical from obstetric providers.
center
United States Prenatal clinic in a rural Low-income African (n = 16) Qualitative study: used
southeastern community American and Caucasian semi-structured focus group
(n = 5) women interviews to elicit perceived
barriers and facilitators to
help-seeking for perinatal
depression.
United Stated Women recruited via Caucasian women previously Qualitative study: used in-
newspaper article and diagnosed with PPD by a health depth interviews to explore
professional network care provider women’s experiences and
contacts perceptions of postpartum
depression (PPD).
England Large teaching hospital (1) 101 black Caribbean Mixed-method study: (1)
and community women and 200 Caucasian Women completed EPDS
antenatal clinics British women; and, (2) a and questionnaires; and, (2)
subset of 12 black Caribbean and individual qualitative
women representing a full range interviews with a purposeful
of depression scores (EPDS) sample to assess women’s
completed individual interviews perspectives on perinatal
depression and help-seeking.
England Large teaching hospital Black Caribbean women Qualitative study: used
and community approximately 6 months in-depth interviews with a
antenatal clinics postpartum selected from larger purposeful sample to explore
sample [55] (n = 301) low treatment and research
participation rates for perinatal
depression.
England Large teaching hospital 12 black Caribbean women Qualitative study: individual
and community selected from larger sample [55] interviews with a purposeful
antenatal clinics (n = 301) representing a full sample to assess women’s
range of depression scores perspectives on perinatal
(EPDS) depression and help-seeking.
England Community settings Black women of Caribbean origin Qualitative study: 5 focus
(e.g. churches) groups with a purposeful
sample of 6-10 women to
explore low levels of treatment
for perinatal depression.
Australia Women living in Middle Eastern women Qualitative study: in-depth
Sydney, Australia individual unstructured
interviews with a purposeful
sample to explore experiences
of PPD.
England General practices within Postpartum women Qualitative study: in-depth
the Oxford City Primary individual unstructured
Care Group interviews with a purposeful
sample to explore acceptability
of PPD screening by health
visitors.
(Continued)
146  N. Byatt et al.
Table I.  (Continued).
Study/sample size
Holopainen et al (2002) [67].
(n = 7)
Abrams et al. 2009 [49]. (n = 37) United States
Kopelman et al (2008) [9].
(n = 1416)
McIntosh et al (1993) [53].
(n = 60)
Kim et al (2010) [11]. (n = 51)
Callister et al (2011) [115].
(n = 20)
Goodman, 2009 [60]. (n = 509)
Slade et al (2010) [65]. (n = 30)
Flynn et al (2010) [97]. (n = 23)
Henshaw et al (2011) [59].
(n = 23)
O’ Mahen et al (2008) [91].
(n = 108)
Journal of Psychosomatic Obstetrics & Gynecology
Country Setting Population of women served Study design and methods
Australia Community mental Women currently suffering from Qualitative study: used
health service or had a recent history of PPD in-depth interviews to elicit
women’s experience of support
and treatment for PPD.
Women, Infant and Three target groups: (1) Qualitative study: 5 focus
Children (WIC) culturally and linguistically groups and 10 in-depth
federal nutrition program diverse (CALD) women with individual interviews to
PPD symptoms year prior investigate barriers to help
(n = 14); (2) community seeking for PPD.
informants; and, (3) health and
social care professionals for
CALD new mothers (n = 12)
United States 4 maternal health centers Women 6-26 weeks Prospective study: using a
and a university based gestational age mixed-methods approach
OB clinic women completed measures
assessing depression severity,
willingness to seek treatment
and barriers to care.
Scotland 3 antenatal clinics First-time mothers Prospective study: assessed
women’s perceptions and
experiences of the condition
and implication on help
seeking.
United States Departmental universal Perinatal women offered mental Prospective study: mixed-
depression screening and health referrals during OB care methods telephone interview
referral program to examine mental health
referral outcomes among
antenatal women at risk of
depression.
United States Community health clinic Immigrant Hispanic women Qualitative study: individual
scoring positive for symptoms interviews to identify barriers
of PPD to seeking mental health
resources.
United States Two OB clinics affiliated Women in third trimester of Descriptive study:
with a large teaching pregnancy questionnaire to examine
hospital women’s attitudes and
preferences toward depression
treatment and perception of
barriers to accessing treatment.
England General primary care Women 6 months postpartum Qualitative study: in-depth
practice with EPDS ≥18 at 6-weeks interviews to explore
postpartum women’s experiences during
identification and management
of depression by health visitors.
United States Five obstetric clinics: Pregnant and postpartum women Qualitative study: used
2 university hospital with EPDS ≥ 9 and not receiving semi-structured interviews to
affiliated and 3 private mental health treatment explore perceptions of barriers
and facilitators to depression
treatment.
United States Five obstetric clinics: Pregnant and postpartum women Qualitative study: used
2 university hospital not receiving mental health semi-structured interviews
affiliated and 3 private treatment to explore perceptions of
interactions with clinicians and
how such interactions affect
seeking help for depression.
United States 4 obstetric clinics: Women seeking prenatal care Descriptive survey study:
1 associated with a via surveys and structured
university hospital and interview assessed barriers
3 part of a nonprofit to treatment and confidence
organization in treatment, providers and
settings compared between
African American and white
women.
(Continued)

Table I.  (Continued).
Study/sample size
Amankwaa, 2003 [57]. (n = 12)
Letourneau et al (2007) [63].
(n = 41)
Segre et al (2010) [28].
Sword et al (2008) [13]. (n = 18)
Woolhouse et al (2009) [62].
(n = 1385)
Mauthner et al (1997) [58].
(n = 18)
Chew-graham et al (2009) [93].
(n = 61)
Barriers and Facilitators Among Obstetric Providers and Staff
Buist et al (2005) [81].
(n = 246 GPs and 525 women)
Coleman et al (2008) [84].
(n = 397)
Buist et al (2006) [80]. (n = 1153) Australia
© 2012 Informa UK, Ltd.
Strategies for improving perinatal depression treatment  147
Country Setting Population of women served Study design and methods
United States Private health care African-American women Qualitative study: used
settings diagnosed with PPD or by individual interviews to
self-report of PPD. examine nature of PPD.
Canada Urban city that offers Report of depression within 12 Qualitative study: used women
systematic PPD screening weeks of delivery semi-structured individual
and program and rural interviews (n = 41) and also
regions without focus groups in a subset
systematic screening (n = 11) to elicit women’s views
on barriers and facilitators to
PPD treatment.
United States Women who recently Sample 1 (n = 691): white, Descriptive survey study of
gave birth in Iowa married, and well-educated two groups to examine model
(sample 1) and women postpartum women; sample 2 in which nurses’ screen and
enrolled in Healthy (n = 132): culturally, counsel women for PPD.
Opportunities for Parents linguistically, and economically
to Experience Success- diverse mothers enrolled in
Healthy Families Iowa HOPES-HFI
(HOPES-HFI) program
(sample 2).
Canada Public health unit’s Women with EPDS ≥ 12 at 4 Qualitative study: used
Healthy Baby, Healthy weeks postpartum in-depth semi-structured
children Program interviews to explore barriers
and facilitators to help-seeking
for PPD.
Australia 6 metropolitan Nulliparous women, Longitudinal study: used
hospitals < 24 weeks gestational age longitudinal questionnaires
and telephone interviews
to investigate help-seeking
behaviors and barriers to
help-seeking for depression.
England Community sources Mothers self-identified as Qualitative study: used semi-
having experienced PPD structured in-depth individual
interviews to explore women’s
experience s with PPD.
United Kingdom 9 Primary Care Trusts 19 general practitioners Qualitative study: in-depth
in inner city and urban (GPs), 14 health visitors, interviews with subjects
areas and 28 women participating in a RCT to
explore subjects’ perspectives
on the disclosure of symptoms
indicative of PPD in primary
care settings.
Australia Division of general GPs, women attending 6-12 week Descriptive survey study:
practice within 34 postpartum visit surveyed GPs and postpartum
maternity hospitals/area women to assess knowledge of,
health services and attitudes toward PPD via
case vignettes.
United States Questionnaires mailed to Obstetricians Descriptive survey study:
1193 obstetricians who surveyed of obstetricians
were ACOG Fellows and diagnostic accuracy for mental
Junior Fellows health issues during pregnancy
via clinical vignettes with
describing depressive and
anxiety symptoms.
Regions throughout Random sample of 246 GPs and Survey study: assessed
Australia to be 338 maternal child health nurses awareness and knowledge
subsequently targeted (MCHNs) and 569 midwives of perinatal depression via
by a screening and involved in perinatal care responses to a hypothetical
education program case vignette and knowledge
questionnaire.
(Continued)
148  N. Byatt et al.
Table I.  (Continued).
Study/sample size
Schmidt et al (1997) [85].
(n = 822)
LaRocco-Cockburn et al (2003)
[86]. (n = 282)
Rothera et al (2008) [92].
(n = 41)
Segre et al (2010) [116].
(n = 520)
Palladino et al (2011) [79].
(n = 20)
Price et al (2012) [76].
(n = 1498)
McCauley et al (2011) [87].
(n = 161)
Thomas et al (2008) [72].
(n = 228)
Logsdon et al (2010) [89].
(n = 43)
Journal of Psychosomatic Obstetrics & Gynecology
Country Setting Population of women served Study design and methods
United States ACOG Fellows Obstetricians/ACOG Fellows Exploratory survey study:
examined depression
diagnosis, treatment,
patient referral patterns and
professional training in the
management of depression
via a questionnaire. Used data
from the National Center for
Health Statistics to validate
data on practice patterns.
United States Washington State ACOG Obstetricians /ACOG members Cross-sectional survey:
members examined obstetricians’
attitudes and practices to
depression screening via a
36-question survey.
England 2 strategic health (1) 39 health professionals; Qualitative study: conducted:
authorities, 6 health general adult and perinatal (1) semi-structured interviews
communities, 4 mental psychiatrists, obstetricians, health with health professionals
health trusts, 12 visitors, midwives, GPs, primary via purposeful and snowball
maternity hospitals and care mental health practitioners, sampling; (2) 2 focus groups
24 primary care trusts and health services managers; with women; and (3) 1 focus
(2) 12 women who had been group with staff from mother
admitted to a mother-baby unit and baby unit.
and had a history of perinatal
mental illness; and, (3) staff from
mother and baby units
United States Surveys mailed statewide Large and diverse sample of Descriptive survey study:
(Iowa) to nurses who met nurses currently working within surveyed nurses to assess
eligibility criteria women’s health, pediatrics, acceptance of nurse-delivered
community health, general postpartum mental health care.
practice, or psychiatry
United States 6 hospital and Obstetricians, nurses, medical Qualitative study: used
community based assistants, social workers and semi-structured interviews
obstetric clinics administrators with each provider to
understand providers’
perception of influences on
perinatal depression care.
United States Statewide health care Physicians, nurse practitioners, Public health survey data
settings in Virginia and certified midwives analysis to evaluate whether
constructs within MI were
linked with improved
depression screening and
treatment/referral.
Australia Antenatal wards, labor Midwives Explorative descriptive survey:
wards, postnatal units, explored midwives attitudes,
special care nursery, knowledge, skills, and
residential units, mother experiences of working with
and baby psychiatric unit women with perinatal mental
of 20 hospitals illness.
United States Northern Carolina Random sample of obstetricians Descriptive survey study:
Physicians Database and family practitioners examined relationship between
characteristics of physicians
providing care for postpartum
women and their preference
for treatment and management
of PPD.
United States Private suburban Hospital-based perinatal nurses Cross-sectional, descriptive,
hospital in southern in labor and delivery and mother/ correlational study: used
United States baby units self-reports instruments to
explore relationship between
self-efficacy and PPD
teaching.
(Continued)
 Strategies for improving perinatal depression treatment  149

Table I.  (Continued).

Study/sample size
Mancini et al (2007) [75].
(women: n = 755; providers:
n = 16)
Delatte et al (2009) [88]. (n = 47) United States
Lieferman et al (2008) [73].
(n = 232)
Skočir et al (2005) [74]. (n = 134) Slovenia
Leddy et al (2011) [82]. (n = 223) United States
Edge et al (2010) [77]. (n = 42)
Buist et al (2006) [78]. (health
professionals n = 916; women
n = 860)
Kim J, et al (2009) [66]. (n = 22)
Price et al (2012) [76] (n = 1498). United States
Country Setting Population of women served Study design and methods
United States Collaborative obstetric 11 obstetricians and 9 midwives Cross-sectional study:
and midwifery practice serving 200 deliveries per year examined use of screening tool.
and 755 postpartum women
Outpatient obstetric Obstetric providers Descriptive survey study:
practices in an academic examined use of EPDS for
medical center detecting PPD.
United States Healthcare settings in 5 Physicians practicing obstetrics, Surveillance study examined
cities in Virginia pediatrics, or family medicine relationships among
physicians’ knowledge, beliefs,
self-efficacy and perceived
barriers and practices toward
perinatal depression.
Urban academic Employed workers with Descriptive questionnaire
maternity hospital and 6 education in midwifery or survey study: examined
community services nursing education working with confidence to manage PPD.
perinatal women
ACOG Fellows and junior fellows of Descriptive survey study:
ACOG examined obstetricians’
attitudes, knowledge, and
practices regarding diagnosis
of PPD and postpartum
psychosis.
England Antenatal community GPs, midwives, hospital doctors, Qualitative study: used
clinics, general practices, health visitors, and voluntary individual interviews and
large inner-city teaching sector providers focus groups to examine health
hospital, and voluntary professionals’ perspectives on
sector agency specialists perinatal mental healthcare
for minority ethnic and Black
women.
Australia 43 maternity hospitals (1) Antenatal and postpartum Survey to examine acceptability
and area health services women receiving care at of perinatal screening.
maternity hospitals; and, (2) GPs
(n-229), maternal child health
nurse (n = 267), and midwives
(n = 305)
United States Academic medical center 19 obstetricians and 3 nurse Descriptive study: used
with private and hospital- midwives structured interviews to
employed faculty examine obstetric care provider
attitudes toward screening
and factors associated with
screening.
Health care Family practice physicians Survey study: public health
practitioners in (n = 299), obstetricians survey regarding practitioners’
Virginia (n = 178), pediatricians practices and perceptions of
(n = 250), and other physicians perinatal depression care to
(n = 272), nurse practitioners inform interventions aimed to
(n = 213), and certified nurse enhance perinatal depression
midwives (n = 74), registered screening and participation in
nurse or social workers (n = 26) mental health treatment.

to screen in the context of structured programs that provide
guidance for obstetric providers and access to mental health
assessment and referral [66]. A combination of staff train-
ing [87,89], structured screening programs, and community
resource guides may help obstetric providers and staff feel
more comfortable detecting and referring or treating peri-
natal depression [90]. Provider and staff training in mental
health can allow obstetric providers and staff to feel more
confident with these discussions [66,84], which may in turn
assuage women’s fears and concerns and activate women to
engage in a range of treatment options including individual
and group psychotherapy [51,58,65,66,75].
Limited mental health treatment resources
Available treatment resources are often limited for both
perinatal women and obstetric providers and staff, creat-
ing both patient and provider barriers, respectively. Women
note numerous factors that impede their ability to seek
and access mental health treatment [9–13,49–52,60,64,67,
91–93], including disconnected pathways to depression care
[10,13,66,75,77]. Sub-optimal interactions between women
and mental health providers also impede engagement in
treatment. Mental health providers can be perceived as unre-
sponsive, unavailable [9,11,70] or uncaring [49] by women.
To improve their knowledge and skills in treating pregnant

© 2012 Informa UK, Ltd.

150  N. Byatt et al.
and postpartum women, additional training on the risks and
benefits of pharmacologic and psychosocial treatments for
perinatal depression is needed for mental health specialists
[18,90,94]. A good first step is to provide resource and refer-
ral source guides for patients and staff. Co-locating mental
health care with the obstetric settings may also be an effective
way to overcome some of these issues [95]. Provider psycho-
education [51,58] about psychiatric resources [51,58,65] may
empower women by increasing their knowledge [68] about
available resources including professional, non-professional
and self-help resources as listed in Table III.
Facilitators
Addressing depression in the outpatient obstetrical setting
through clinical, program, and system level changes
Strategies at clinical, program, and system levels can be uti-
lized to help obstetric outpatient programs better address peri-
natal depression [11,13,96]. Clinical level interventions target
the complex patient-provider relationship through education
and other motivational enhancement interventions to improve
screening processes and treatment engagement. Program level
interventions often involve a team of providers and/or staff and
focus on quality or performance improvement. As summarized
in Table IV, many facilitators have been identified by women
and obstetric providers in qualitative and descriptive studies
as presented in Table I. Examples of program level enhance-
ments include changes in referral and screening processes,
provider/staff training, and efforts that provide more patient
and family centered care [8,11,13,60,66,92,97]. Improved
clinical documentation “triggers” within an electronic medi-
cal record [66] and increased monitoring of clinical outcomes
can be useful in promoting culture changes that help providers
and staff address depression [18]. Broader system-level inter-
ventions can occur within or in collaboration with agencies or
across multiple programs. For example, interventions or policy
changes aimed to combine mental health and perinatal care
could improve alliances, partnerships and promote seamless
perinatal depression care in outpatient obstetric settings.
Clinical level interventions
Providers and staff can be trained to combine screening with
education and other motivational enhancement interven-
tions that may inspire women to engage in treatment. For
example, information about health risks, wellness interven-
tions, available support groups, psychotherapy, medication,
and other community resources can encourage women to
address their depression. Motivational Interviewing (MI)
is a patient-centered interviewing style that helps clinicians
to successfully promote behavioral change in a wide variety
of medical and behavioral circumstances. MI can improve
medication compliance, initiation and maintenance of new
behaviors, discontinuation of harmful behaviors [98], and
treatment engagement and retention [99]. A recent survey of
perinatal healthcare providers examined programmatic the-
ory components of a MI intervention. While limited by inher-
ent measurement error, small sample size of specific provider
groups, and recruitment of subjects from one geographic area,
the results support the use of MI as an intervention that may
Journal of Psychosomatic Obstetrics & Gynecology
positively influence provider practices and attitudes toward
perinatal depression screening and treatment [76].
Program level interventions
Program level interventions include staff training and
implementation of universal screening with structured and
stream-lined referral processes aimed to integrate depression
and obstetric care [18]. Such program level interventions are
needed because systematic screening and referral alone do
not translate into treatment engagement [42]. While several of
the available studies summarized in Table V have promising
data [44,45,95,100], the available studies examining perinatal
depression program level interventions in obstetric settings
are limited by lack of comparison groups. Additionally, many
studies do not assess treatment participation or depression
outcomes among women and most do not provide data on
why women did or did not engage in treatment.
For example, a Perinatal Depression Management Program
[45] introduced stepped-care management through on-site
diagnostic assessment in obstetric clinics. In stepped-care mod-
els, screening, diagnosis and treatment begin in a primary care
setting and if depression persists, the patient is offered additional
follow-up, monitoring, patient education, support, mental health
consultation and/or referral by a care manager [101]. In the
Perinatal Depression Management Program, 72.0% of women
who screened positive received on site diagnostic assessment;
this is significantly greater than previous studies [22,27,41],
results of 0 [42] to 30% [27,41] rates of subsequent mental health
assessment or follow-up in screen positive women. While the
former results are promising, it is difficult to draw conclusions
without a comparison group, without reported depression out-
comes among women, and without assessed or even speculated
reasons for their high acceptance rate of onsite diagnostic evalu-
ations [101]. As part of a similar stepped-care approach [100],
the Perinatal Mental Health Project implemented training for
perinatal health care workers, routine antenatal depression
screening, and a referral network to on-site counselors and
mental health professionals. While the project demonstrated the
approach to be feasible and acceptable, it also lacked a compari-
son group and did not assess depression outcomes or reasons
for high acceptance rates among women [100]. Although not
specific to obstetric providers and staff, a randomized controlled
trial in family medicine and pediatric clinics compared stepped-
care to usual care; stepped-care improved mothers’ awareness of
depression and increased the likelihood of getting treatment, yet
did not impact duration of treatment, work or health outcomes
[64]. This study is limited by its small sample size and inclusion
of women with other chronic mental illnesses.
Another depression screening program [44] utilized
screening with nursing and physician education, a hotline
staffed by mental health workers, a mental health provider
network to accommodate referrals, and a centralized refer-
ral system in 20 private and employed obstetric groups.
Department-based, perinatal depression screening was feasi-
ble when done with the necessary infrastructure to respond to
at-risk patients [44]. However, they did not assess the satisfac-
tion of women and providers, impact on treatment duration
and follow-through, or depression diagnosis among women.
 Strategies for improving perinatal depression treatment  151

Table II.  Barriers to perinatal depression treatment.

Patient level Barriers
Lack of time [11,60,62,64], transport and/or childcare [9,49,50,60,61,64,91]
Unfamiliarity with depression and/or perinatal depression [9,10,13,52,54,55]
Unawareness or lack of access to mental health treatment options or resources [8,9,53,54,60,61,63,91]
Concerns about risks of medication use in pregnancy or lactation [9,63,66,93]
Perception that can work through things herself [11,52,57,62,64] or that other supports can be used [11,49]
Lack of motivation and hopelessness about treatment working [62,91]
Waiting until symptoms resolve on their own [10,13,57,62–64]
Normalization of depression symptoms [10,13,62,63]
Discomfort or avoidance of mental health discussions [10,13,57,63]
Stigma [9,10,12,49–57,60–63,66]
Fear of failing as a mother [10,13,49,57–59,65] or losing parental rights [12,13,49,53,58,64]
Fear of being judged by providers [9,12,49,53,58,59,65]
Negative prior experiences with mental health treatment [9,12,49,50]
Family and friends discourage help seeking [9,10,12,13,49,53,64]
Cultural/language barriers [49,57,60]
Fear of psychiatric hospitalization [9]
Women perceive obstetric providers as unresponsive and/or unsupportive [8,12,59,69,70]
Women feel symptoms are minimized or dismissed as self-limited by health care providers [10,12,13,58,59,63,69–71]
Perception that midwives are afraid to discuss depression [58]
Perception that obstetricians are not qualified and/or do not want to treat depression [8,70]
Perception that obstetric and mental health care are not related and obstetricians is not the typical doctor for depression [8]
Lack of time [11,60,62,64], transport and/or childcare [9,49,50,60,61,64,91]
Provider level barriers among obstetric providers and staff
Obstetricians under-detect depression [63,86]
Low depression (44%) screening rates [86]
Focus on infant, rather than mother [69]
Lack of time to address psychological needs [8,69]
Lack of continuity [8]
Nurse midwives perceive that clinical settings prioritize health of children over maternal health [49]
Obstetricians [66,75,76], and midwives [75,77,78] feel they lack the needed skills needed to discuss depression
Obstetricians perceive women are unwilling to talk about mental health issues [73,75] and concerned about stigma [73]
Liability concerns [73]
Obstetricians [73,75,79,82] and nurse midwives [49,75] perceive lack of time [66,77,82], resources [66,77], referral sources [66], and inadequate
reimbursement [76]
Self-identification as a specialist associated with lower screening rates [85]
Lack of screening documentation [88] or office prompt to screen [66]
Lack of counseling about depression by providers [88]
Obstetricians [73,79,82,84–86] and midwives [78,87] report inadequate or barely adequate training
Midwives uncertain how to differentiate reaction to external stressors from PPD symptoms [49]
Lack of flexible and easy referral system [66,75–77,79]
Lack of responsibility for arranging mental health follow-up among obstetricians [73]
Obstetricians report being skeptical about efficacy of screening [66] and/or perceive woman as unwilling to accept medications, receive counseling or
accept diagnosis [82]
Limited Mental Health Treatment Resources
Difficulty with cost [60]
Long wait times for mental health appointment [9]
Women do not know who to call or where to go for help [9]
Disconnected pathways to depression care[10]
Lack of mental health providers willing to see pregnant women [79] Long wait times for mental health appointment [77]

A tertiary referral obstetric hospital in Australia devel-
oped an Early Motherhood Services (EMS) which included:
(1) community educational activities to increase awareness
among women and families; (2) resources for women and
health care providers; (3) co-located or home treatment for
women and consultation to health care provider; and, (4)
education, training and capacity building for providers [95].
While the reduced depression severity in the subset of women
who engaged in the EMS [95] suggests that EMS is a promis-
ing program, the study design has weaknesses that preclude

© 2012 Informa UK, Ltd.

152  N. Byatt et al.
Table III.  Resources for perinatal depression.
Telephonic Support for Women
Perinatal Mental Health Consultation Line
PPDMoms Hotline
Parental Stress Line
Postpartum Support Warm-line
Online Support for Women
Postpartum Support International
Postpartum Progress
Jenny’s Light
Parenting Resource Directory
La Leche League
Telephonic Support for Providers
Perinatal Mental Health Consultation Line
Online Support for Providers
MedEdPPD
LactMed
Massachusetts General Hospital Center
for Women’s Mental Health
Support and Training to Enhance
Primary Care (STEP)-PPD
MotherRisk
Postpartum SupportInternational
any firm conclusions about its success, including absence of
a comparison group, bias toward women who engaged in
treatment, and lack of data on women who did not engage in
treatment.
Several other studies examining co-located obstetric and
perinatal depression care initiatives [32,102], supportive
Journal of Psychosomatic Obstetrics & Gynecology
Consultation for health care providers who have questions (800) 573-6121
about the detection, diagnosis and treatment of perinatal
depression and anxiety disorders. Consultants are
University of Illinois Chicago faculty and staff clinicians:
psychiatrists, an advanced practice nurse and a social
worker.
Available support 24 hours a day, 7 days a week for the (800) PPDMOMS or (800) 773–6667
mothers and their family and/or friends. Offers support,
information and referrals.
A statewide parental stress-line that is available 24 hours a (800) 632–8188
day, 7 days a week; staffed by trained volunteer counselors
who are sympathetic and non-judgmental.
Confidential information, support and listings of local (866) 472–1897
resources. Women can leave a message and a volunteer will
return call within 24 hours.
Information for mothers, family and professionals. There is www.postpartum.net
a weekly Phone Chat with an expert.
Provides educational material and resources. postpartumprogress.com
Provides educational resources and peer-to-peer support. www.jennyslight.org
An extensive community resource guide for families; online www.parentingdirectory.org
and at libraries and other locations. Information on Family
Centers, Housing, Medical and Food assistance, and social
activities.
International organization dedicated to providing www.lalecheleague.org
information and support to pregnant and breastfeeding
women.
Consultation for health care providers who have questions (800) 573–6121
about the detection, diagnosis and treatment of perinatal
depression and anxiety disorders. Consultants are Univer-
sity of Illinois Chicago faculty and staff clinicians: psychia-
trists, an advanced practice nurse and a social worker.
Web site developed with the support of the National Insti- www.mededppd.org
tute of Mental Health (NIMH) to provide education about
postpartum depression (PPD). Includes screening tools,
interactive case studies, literature, provider tools, CME
modules, and resources.
A peer-reviewed and fully referenced database of drugs toxnet.nlm.nih.gov
to which breastfeeding mothers may be exposed. Among
the data included are maternal and infant levels of drugs,
possible effects on breastfed infants and on lactation, and
alternate drugs to consider.
Online perinatal and reproductive psychiatry information www.womensmentalhealth.org
center.
Web-based education to give primary care providers www.step-ppd.com
up-to-date information on evidence-based approaches for
assessing and treating PPD. Website includes case studies,
interactive video clips, didactic information and links to
additional resources.
Provides educational material and resources. www.motherisk.org
Information for mothers, family and professionals. There is www.postpartum.net
a weekly Phone Chat with an expert.
psychotherapy and case management services [103], and
nurse delivered feedback and referrals for perinatal depres-
sion [42] show that these interventions may increase the
likelihood of seeking treatment. These studies however, are
limited by small sample size, lack of comparison groups and
lack of data on depression outcomes and reason for treatment
 Strategies for improving perinatal depression treatment  153

Table IV.  Facilitators to perinatal depression treatment.

Women
  Encouragement to attend treatment [11]
  Recognition of depression [63] and mental health needs [11,58,63,69] and support [67]
  Flexible referrals tailored to patient needs [9,11,12,59,69]
  Active facilitation of referral process by providers [10,11]
  Referral process with minimal steps required [10,58]
  Timely mental health appointment [9–11,13]
  Family, friend, partner [9,10,12,13] or health provider [9,12] support
  Mental health treatment in the home [9] or obstetric clinics [9,28,60]
  Providers who facilitate trust [51,65] and are genuine, warm and optimistic [59]
  Feeling heard by provider: feeling unjudged, listened to and autonomous [58,75]
  Reassurance from providers that feelings are common [51] and treatable [63]
  Psychoeducation [51,58] and resources from providers [51,58,65]
  Involvement of family nurse [67]
  Insurance match [11]
  De-stigmatizing depression [9,59,75]
  Open discussion about depression before and after birth [58]
  Discussion of screening results by obstetric providers or staff [75]
  Depression counseling from obstetric nurses, physicians or social workers [28]
Obstetric providers and staff
  Obstetricians and midwives [66,75] report being more satisfied when they have additional contact and feedback from mental health providers
  Self-efficacy among nurses [89]
  Access to mental health assessment [66]
  Standardized screen that is easy to use [66]
  Increased depression awareness among women and obstetric health care professionals [66]
  Established office prompt for screening [66]
  Integration of screening into established clinic procedures [66]
  Invested point person “champion” [66]
  Setting expectations [66]
  Nurse-delivered counseling after depression screening [116]

engagement. Other studies examining the impact of train-
ing [68,104] and CME courses [105] on perinatal health care
providers do not assess what led or did not lead to increased
mental health literacy and have methodological limitations
that may introduce sample bias.
System level interventions
System level changes go beyond one obstetrical program or
site and may include many obstetrical programs or systems
working with other providers, including those from the
mental health arena. For example, in 2006 a systems level
intervention was federally funded in the United States in the
states of Illinois, Iowa, Kentucky, Louisiana, Massachusetts,
and Pennsylvania; they each participated in a 2-year project
to develop and evaluate novel approaches to improve detec-
tion and treatment of perinatal depression and anxiety. While
providers were able to acquire and retain the knowledge and
skills needed for diagnosis and treatment of perinatal depres-
sion and anxiety disorders [106], it did not examine the impact
on provider knowledge and attitudes, and patient outcomes; it
was subject to further survey bias.
As summarized in Table VI, several other disciplines have
implemented and tested system level changes to address issues
similar to that of perinatal depression. The Massachusetts Child
Psychiatry Access Project (MCPAP) provides an example of a
partnership with psychiatry that helped pediatricians with
child and adolescent psychiatric cases [107]. MCPAP’s driv-
ing goal is support of the pediatrician as a front line provider
of mental health care; it does this by providing pediatricians
with rapid access to child psychiatry training, referral assis-
tance, and expertise [107]. Due to its remarkable success, 95%
of Massachusetts pediatricians are enrolled in MCPAP and
MCPAP has expanded to become the National Network of Child
Psychiatry Access Programs [108]. Despite MCPAP’s accepted
subjective success, similar to other studies its quantified results
are based on unvalidated survey data and suffer from absent
comparison groups and patient outcome data. Regardless, this
approach is felt to be innovative, sustainable and an industry
standard from which aspects could be modeled and adapted to
address perinatal depression in obstetric settings.
Another example of a successful organizational change
model is the Addressing Tobacco Through Organizational
Change (ATTOC) program [109], which has helped agencies
integrate and adapt their treatment culture to address well-
ness and addiction using patient-centered recovery. In com-
paring staff and clients pre- to -post intervention, staff beliefs
became more favorable toward treating tobacco addiction and
both prescription dispensing and use of tobacco treatment
increased [110]. However, this data is limited by subjects liv-
ing in residential treatment programs only, small number of

© 2012 Informa UK, Ltd.

 Table V.  Program level interventions.
Study Intervention Tested
Jardi et al (2010) [104]. Three-hour midwife training
program and posters that
conveyed PPD treatment
recommendations.
Health Care Setting, Country,
and Population served. Study Design and Methods n Findings
Maternity unit of a university Two-stage pre-and-post Before training (control group): After training, early detection
hospital in France that has controlled study. 472 postpartum women in the of major depressive episodes
approximately 4800 deliveries Midwives assessed before and maternity unit; 112 with EPDS increased by 37.7% (95% CI:
per year. after training to determine >10 and random sample of 120 25.7–49.7). Detection of minor
154  N. Byatt et al.

Leddy et al (2012) [105].
Judd et al (2011) [95].
Gordon et al (2006) [44].
correlation between: (1) early
clinical assessment by midwives
and EPDS; and, (2) postpartum
week 1 clinical assessment and
MINI DSM IV interview.
Continuing Medical Education American College of Obstetri- Descriptive survey study.
(CME) courses on PPD. cians and Gynecologists Compared knowledge,
(ACOG) in the United States. attitudes, and behaviors
regarding PPD and postpar-
tum psychosis in CME course
takers versus non-CME
course takers.
Early Motherhood Services Perinatal care provided via a Stakeholder evaluation, analysis (1) Data available for 375 of 537 (1) Average of (SD) 6.81 (6.75)
(EMS): provided resources and shared care model with GPs or a of available outcome data and
co-located or home treatment for midwifery care model provided consumer feedback. Stake-
women, mental health consulta- in a small regional city in holder evaluation: interviews
tion for health care provider, and Australia to perinatal women. with stakeholders. Outcome
education, training and capacity data evaluation: compared
building for providers. EPDS and HoNOS (Health of
the Nation Outcomes Scale)
scores at the time of referral to
EMS (Time 1) to the EPDS at
discharge (Time 2). Consumer
feedback: subset of consumer
completed 7-item feedback sur-
vey after discharge from EMS.
Depression screening program Private and employed physician Reviewed results of depression 4,322 of 9,178 women com-
with nursing and physician groups in an obstetrics and gyne- screening (28 and 32 weeks
education, a hotline staffed by cology department in the United gestation and 6 weeks postpar- years.
mental health workers, a mental States serving approximately tum) program implemented at
provider network to 1,000 deliveries per year. 20 outpatient obstetric practice
accommodate referrals, settings.
and a centralized scoring
and referral system.
women with EPDS <10 depression did not increase.
After training (intervention
group): 343 postpartum
women; 112 with EPDS >10
and 110 with EPDS <10.
400 obstetricians who were fel- Increased rates of screening and
lows or junior fellows of ACOG use of validated screening mea-
completed survey. sures among CME course takers.
CME courses not associated with
change in obstetricians’ knowl-
edge and behaviors toward PPD/
postpartum psychosis.
referred to EMS; (2) 296 women days between referral and first
completed EPDS at Time 1 and assessment; (2) Of the 101 women,
172 at Time 2; 168 completed the initial EPDS was [mean
EPDS at Time 1 and 2. 60% (SD) = 13.75 (5.75)], higher than
(n = 101) scored one page 13. the EPDS on discharge was [mean
(3) 107 women seen by EMS (SD) = 4.52 (2.74) t ((176) = 2.39;
were surveyed. p < .00005). (3) 84.1% of women
(n = 90) strongly agreed and
15.9% agreed (n = 17) they were
satisfied with the services [mean
(SD) = 4.84 (0.37)]; 79.3% strong-
ly agreed (n = 79) and 26.2%
agreed the treatment helped them
[mean (SD) = 4.74 (0.44)].
449 (8.8%) of 4,038 antenatal
pleted 4,558 screens over two women screened positive for
depression. 7.3% of 520 postpar-
tum screens were positive. Crisis
hotline received 524 calls, 328
women referred to urgent care/
triage, of which 16% were not
clinically indicated, 11% were
already in mental health treat-
ment, 6% declined referrals, and
4% could not be given referrals
because they were out of state.
(Continued)

Journal of Psychosomatic Obstetrics & Gynecology
 Table V.  (Continued).
Study
Gjerdenjen et al (2009) [64].
Intervention Tested
Stepped collaborative care mod-
el; screening and diagnosis in
clinic and if depression persists,
additional follow-up, monitor-
Health Care Setting, Country,
and Population served.
4 urban university-affiliated
family medicine residency
clinics, 3 suburban, private
pediatric clinics in the United
Study Design and Methods
Randomized controlled trial:
depressed women randomized
to stepped care or usual care. 9
month health, work, and
n Findings
506 women completed surveys Improved mothers’ awareness
at 0,1,2,4,6 and 9 months (n = 19) of depression and
postpartum and a SCID. 5 increased likelihood of getting
women had SCID-positive treatment compared to usual care

© 2012 Informa UK, Ltd.

Miller et al (2009) [45].
Honikman et al (2012) [100].
ing, patient education, support, States during well-child visits. treatment outcomes evaluated depression and 122 had self- (n = 20); did not significantly im-
mental health consultation or for stepped care versus usual diagnosed depression. Of 45 pact duration of treatment, work
referral by a care manager is care, and women SCID-positive women, 19 or health outcomes.
offered. self-diagnosed with participated in stepped care
depression versus and 20 participated control
nondepressed. group.
Perinatal Depression Manage- Federally Qualified Health Case Study of PDMP: 35.1–84% of 2191 women Of 17.1% of women needing fur-
ment Program (PDMP): on-site Center in Chicago in the examined feasibility and screened per month. ther assessment, 72.0% received
diagnostic assessment in obstet-United States serving > 16,000 acceptability of PDMP. on site diagnostic assessment.
patients and > 1,000 birth per
ric clinics, expert mental health Examined screening. referral High acceptance rate (98.6%) of
consultation to obstetric pro- year. Clinical staffing included and treatment rates. on-site diagnostic screen.
viders, reference guidelines forfamily practice physicians (4
prescribing of antidepressants, full time equivalent, or FTE),
systematic referral to mental midwives (4 FTE), obstetri-
health setting when indicated, cians (2.1 FTE), pediatricians
and a Quality Monitoring sys- (2.1 FTE), internists (1.0
tem to track women screened in FTE), nurse practitioners (1.0
the perinatal care setting. FTE), and a social worker (1.0
FTE), all fluent in English and
Spanish. Clinic population is
94% Mexican American, 90%
Spanish-speaking. 90% are
at or below the 200% federal
poverty level, and 13.2%
unemployed.
Perinatal Mental Health Project A secondary level, university Case study of PMHP: 90% of 6347 women offered Of 95% (n = 5407) screened, 32%
(PMHP): training for health affiliated maternity hospital in examined acceptability and screening with EPDS and Risk with EPDS ≥ 13 were referred
care workers, routine antena- an urban setting, Cape Town, feasibility of PMHP. Factor Assessment (RFA). to a counselor and 62%
tal depression screening, and South Africa. Provides care to (n = 1079) agreed to be referred.
referral networks to on-site ~ 150 women with low obstet- 1,981 counseling sessions
counselors and mental health ric risk from surrounding areas conducted and 2% (n = 20)
professionals. per month. were referred to a psychiatrist.
Women received an average of 2.7
counseling sessions, 832 of which
were first sessions. 88% of subjects
reported being more able to cope
with their presenting problem due
to the counseling.
(Continued)
Strategies for improving perinatal depression treatment  155
 Table V.  (Continued).
Study
Sit et al (2009) [102]
Kuosmamen et al (2010) [32].
Chen et al (2011) [103].
Rowan et al (2012) [42].
Buist et al (2007) [68].
Flynn et al (2006) [117].
Journal of Psychosomatic Obstetrics & Gynecology
Intervention Tested
HS CARES (Healthy Start
Collaboration for Assessment,
Referral, Evaluation, and
Stabilization): screening and
co-located perinatal depression
care.
PPD screening and treatment
in maternity and child health
clinics: Co-located cognitive
behavioral therapy-with a
mental health nurse.
PPD Intervention Program:
(1) postpartum EPDS screen-
ing; and, (2) individualized in-
tervention (supportive therapy
and counseling in perinatal
depression) using a case
management multidisciplinary
team model.
Systematic depression screen-
ing and referral.
Enhanced PPD screening:
(1) screening program; (2)
training and support for
midwives, MCHNs, GPs and a
range of student health in how
to discuss mental health issues;
and, (3) educational booklet.
Depression screening with sys- University hospital obstetrics
tematic follow-up: (1) treating clinic in the Unites States
physician notified of EPDS ≥10; serving privately insured (87%), completed study interviews at
(2) nurse-delivered depression Medicaid (10%) and self-pay/
feedback and referral. other (3%).
Health Care Setting, Country,
and Population served. Study Design and Methods
A university-based research Feasibility study: examined
clinic with a focus on perinatal screening and treatment rates
mood disorders in the United in women with a confirmed
States. Served pregnant and up diagnoses of depression (via
to 1 year postpartum Healthy EPDS and PRIME-MD)
Start clients.
3 maternity and child health Case study: examined
clinics in Finland serving 550 screening, referral and
births per year. treatment rates among women
with EPDS ≥13 at 8-week
postpartum visit.
2 outpatient obstetric clinics Prospective cohort study:
in Singapore, providing care to measures taken at baseline
2000 postpartum women (first intervention) and a 6
annually at 2-6 weeks post months or discharge.
delivery.
Large multi-specialty organiza- Feasibility study: examined
tion with 19 clinics and over detection, referral, and treat-
300 physicians in the United ment rates.
States, serving an ethnically
diverse population of over
400,000 patients.
Compared responses to
43 maternity hospitals/area and
hypothetical depression case
district health services, mainly
in public university-based and depression risk and help
hospitals and some private, seeking behavior using EPDS
rural and remote locations between women who
participated in screening
in all states and 1 territory in
Australia. (Group 2) program and those
that who had not (Group 1).
Longitudinal study: preg-
nant women with EPDS ≥10
baseline, 1 month after
baseline and 6 weeks
postpartum.
n Findings
29 women with EPDS ≥10
agreed to enter CARES
program.
166 with EPDS ≥13 at 8 week
postpartum visit participated
in mental health nurse sessions. attended 3-8 meetings and 25%
2148 eligible women; 64%
(n = 1367) participated in
screening.
2199 eligible women; all 2199
participated in screening at
the first prenatal visit and 569
participated at the 6-week
postpartum visit.
1309 women; 414 in Group 1,
of which 394 completed
majority of questionnaire, 895
in Group 2, of which 612
completed majority of
questionnaires.
1298 women screened with
EPDS, 16% (n = 207) scored
≥10, 60 women completed all
interviews.
55% (n = 16) participated in the
evaluation and 50% (n = 8) at-
tended ≥ 1 follow-up visit. Wom-
en who attended the follow-up
156  N. Byatt et al.
visit found medication and skills
training reduced their symptoms
and enhanced their functioning.
53% of women (n = 88) had 1-2
meetings with health nurse, 22%
(n = 41) attended 1 group meet-
ing.
95% satisfied with screening and
71% with educational interven-
tion, 31% (n = 42) accepted
referral to psychiatrist and 32.5%
(n = 41) participated in PPD
intervention.
Of the 2199; 18.7% (n = 412) had
an EPDS score ≥9 and 4.6%
(n = 102) had an EPDS score ≥14
and none followed the recom-
mendation to seek behavioral
health assessment. Of the 569 that
participated in postpartum screen-
ing; 4.9% (n = 28) had an EPDS
score ≥14 and 17.9% (5 of the 28)
followed recommendations to seek
behavioral health care.
Response rates 57% for Group 1
were 62% and for Group 2. Group
2 was better able to recognize
depression (60.4% vs. 47.1%) in
a hypothetical case and to assess
their own mental state than
Group 1, yet it was not statisti-
cally significant.
65% of women with MDD were not
receiving treatment, the 67%
(n = 49) reported physician dis-
cussed depression and were more
likely to seek treatment by the 1
month prenatal follow-up but not at
the 6 week postpartum follow-up.
 Table VI.  System level interventions.
Study
Obstetric Setting
Shade et al (2011) [106].
© 2012 Informa UK, Ltd.
Other Settings
Sarvet et al (2010) [107].
Guydish et al (2012) [110].
Intervention Studied
Integrated Obstetric and Mental
Health Care Program:
(1) provider-education (training
workshop);
(2) infrastructure-building and
interventions to improve
service-delivery; (3) screening and
treatment tools; and, (4) access to
consultation with specialists.
Massachusetts Child Psychiatry
Access Project (MCPAP): (1)
combination of real time telephonic
psychiatric consultation, care
coordination services and
professional education.
Addressing Tobacco Through Orga-
nizational Change (ATTOC) utilizes
seven core strategies: (1) activities
related to preparation for initiation of
the intervention, (2) on-site tobacco
treatment specialists (3) identification
of ATTOC leaders, (4) work group
formation to carry out the 12-Step
ATTOC approach (5) in person con-
sultation and (6) ongoing phone con-
sultations for expertise and advice, and
(7) web based training and support.
Country and Health Care Setting
and Population Served
1,679 providers in Illinois and
nearly 1,500 in Pennsylvania in
the United States.
Hosted by a division of child
psychiatry within regional
academic medical centers in
Massachusetts in the United
States. MCPAP team consists of
~1 full-time (FTE) equivalent
psychiatrist, 1 FTE child and
family psychotherapist, and 1
FTE care coordinator.
Three large multi-service ad-
diction treatment organization
agencies with residential addic-
tion treatment programs in three
states in the United States.
Study Design and Methods
Piloted and tested provider
education strategies: as-
sessed provider knowledge
pre- and post-workshop.
Measured MCPAP provider
participation and utilization
over 3.5 years for 35,335
encounters.
Evaluated 6 month ATTOC
intervention: surveyed pro-
gram and staff and clients
pre- to post-intervention,
and at 6 month follow-up.
n Findings
77 obstetric providers, Ability to name a validated depression
92 maternal and child screening tool increased from 27.2%
health staff. (n = 28) to 96.2% (n = 99) among
providers (n = 103).
Knowledge of obstetric risks of
untreated antenatal depression
increased from 18.4% (n = 19) to 87.3%
(n = 90) among providers (n = 104).
Ability to correctly understand Food
and Drug Administration pregnancy
risk categories increased from 9.4%
(n = 9) to 79.2% (n = 76) among
providers (n = 96). Knowing a source
of evidence-based information about
antidepressants during pregnancy and
breastfeeding increased from 30.6%
(n = 29) 78.5% (n = 77) among
providers (n = 98). Knowledge
increased from 63% (n = 47) before the
workshop to 87% (n = 47) at the end of
the workshop and was 81% (n = 26) at
8-week follow-up.
1341 primary care > 90% respondents in year 1 and 2
clinicians in 353 agreed or agreed strongly that MCPAP
practices; 514 (38%) consultations were useful. Percentage
completed baseline that agreed there was adequate access to a
survey. Of 524, 385 child psychiatrist increased from 5–33%.
(75%) completed Percentage who agreed or strongly
follow-up survey(s). agreed they were able to meet the needs
10,114 children served of child with psychiatric problems
by MCPAP. increased from 8–63% and the % able to
obtain child psychiatry consultation in a
timely manner increased from 8–80%.
Site 1: 54 staff and 40 Staff beliefs became more favorable
clients toward treating tobacco dependence
Site 2: 43 staff and 50 (F(1, 163) = 7.15, p = 0.008) and use
clients, of nicotine replacement treatment
Site 3: 17 staff and 20 increased. Client attitudes toward
clients. treating tobacco dependence also
became more favorable (F(1, 235) =
10.58, p = 0.0013) and clients received
more tobacco-related services from
their program (F(1, 235) = 92.86,
p < 0.0001) and counselors (F(1, 235) =
61.59, p < 0.0001).
Strategies for improving perinatal depression treatment  157
158  N. Byatt et al.
clinical sites, small sample size with potential for confounding
by factors such as local or state changes in tobacco policies,
and lack of patient outcome data. Recognizing these limita-
tions, several of ATTOC tactics could be adapted for perinatal
depression, for example the use of improved documentation
of assessment and treatment, integration of screening tools,
and psychosocial treatment offerings.
Discussion
With rising public health concerns about perinatal depres-
sion, the development of a successful multidisciplinary
approach that includes strategies to enhance clinical, pro-
gram, and system level change is paramount. Obstetric set-
tings and practices have a unique opportunity to address
perinatal depression. While there are clear barriers to
addressing perinatal depression, there are also effective ways
to address these barriers while promoting the integration
of obstetric and mental health care. Training of all relevant
health professionals and staff is imperative for successful
implementation of screening programs that engage women
in treatment [18], yet it needs to be supplemented with addi-
tional programmatic changes. While midwife training [104]
and obstetrician Continuing Medical Education courses on
postpartum depression (PPD) [105] have been associated
with increased rates of detection [104], and screening rates
[105], such training has not been associated with change in
obstetricians knowledge, attitudes and behaviors toward PPD
[105]. Implementing PPD screening with education is not
enough to engage women in interventions targeted to treat
depression [37]. In order to improve treatment participation,
screening programs must go beyond simply screening and
integrate obstetric and depression care.
Stepped-care models, in which screening, diagnosis and
treatment begin in a primary care setting, may provide a
model for perinatal depression care in the obstetric care set-
ting [101]. Access to women’s mental health providers could
be improved by increasing availability via telephone con-
sultation, one-time patient consultation, ongoing treatment
within mental health programs and co-location of psychiatric
services within obstetric clinics [60,95]. Improvement can
be monitored through peer audits of clinical charts, refer-
ral tracking and self-report scales [111]. Successful treat-
ment outcomes communicated via newsletters, websites,
and other mechanisms can provide evidence that treatment
leads to enhanced mental health for baby, mother, and family.
Strategies used to sustain change include policy changes and
the creation of standard operating procedures [112].
Programs that provide treatment for perinatal women will
have their own unique treatment culture with inherent chal-
lenges. For example, in the perinatal setting, barriers related
to staff include lack of training, misconceptions, and beliefs
that depression does not fall within their treatment purview
[66]. Strategies that engage both providers and women in
treatment can facilitate identification and referral to treatment
among obstetric providers. Obstetric provider discussions of
depression with patients is not enough; it impacts treatment
entry in the short-term, yet not in the long-term [10]. Other
Journal of Psychosomatic Obstetrics & Gynecology
facilitators include provider training [90,109,113], structured
universal screening and referral, linked obstetric and mental
health medical records [45,100,106] and increased access to
resources for women.
Enhanced provider training can lead to improved detec-
tion and less misconceptions and stigma surrounding mental
health treatment. Interventions aimed to improve obstetric
knowledge base and communication skills, may result in
improved screening and referral rates. Nursing staff can also
be utilized to perform screening and provide psycho-edu-
cation. Social work, nursing and clerical staff can be trained
to make the referral process seamless, flexible and timely to
decrease women’s perception that mental health providers
are not responsive or available. Routinely offering depression
treatment in obstetric clinics can enable providers to form
liaisons with mental health providers and ease the refer-
ral process, while providing a low stigma setting in which
their patients can obtain care. System Integration Programs
such as the Integrated Obstetric and Mental Health Care
Program, Massachusetts Child Psychiatry Access Project, and
Addressing Tobacco Through Organizational Change offer
models to address the mental health needs of perinatal women
and the environments in which they get care. Finally, screen-
ing will be more successful if accompanied by a clear role for
obstetricians as to how to refer and/or manage treatment.
System changes likely include the need for enhanced col-
laborations and possibly the need for memoranda of agree-
ment. Funding for system change is often more complicated
and can require State or Federal level funding support. With
changes in health care reform, large agencies and networks are
making system changes to improve quality of care and reduce
costs. The delivery of treatment for perinatal depression
could be improved through new evidenced-based policies
and legislation aimed to change how health care is organized.
Examples include legislation that establishes mental health
parity with physical illness, and the establishment of financial
support for perinatal depression care from public and private
insurers [114].
Despite a substantial body of evidence suggesting that
strategic changes are greatly needed to successfully refer
and engage perinatal women in depression treatment, there
remains a dearth of information on how to successfully do
so. Future studies should extend previous work on patient
barriers by focusing on complex patient-provider interactions
contributing to untreated perinatal depression. Obstetric pro-
viders should be supported in their role as front line providers
to perinatal women through structured universal screening
and referral, provider training and consultation, and super-
vision with mental health professional collaboration. Future
program-level interventions should aim to integrate depres-
sion screening and treatment into routine perinatal care
through organizational changes that aim to increase access to
and engagement in perinatal depression treatment.
Declaration of interest: The first author has received grant
support for perinatal depression research from the Meyers
Primary Care Institute/Rosalie Wolf Interdisciplinary
Geriatric Healthcare Research Center Small Grants Initiative.

The second author has no declarations of interest. This
third author’s spouse is a research scientist working in the
pharmaceutical industry. He currently works for Infinity
Pharmaceuticals and in the past five years has worked for
Biogen and Pfizer.
The fourth author has no declarations of interest. The fifth
author has received research funding support from the NIH,
Legacy Foundation, Massachusetts Department of Mental
Health, Connecticut Department of Public Health, and
SAMHSA.
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Current knowledge on this subject

• Despite the deleterious effects of perinatal depression, barriers hinder screening, assessment, and treatment in the
outpatient obstetrical setting.
• Depression is often not fully integrated into obstetrical care.
•Major changes in current practice patterns are needed to improve treatment for perinatal depression.

What this manuscript adds

• Identifies barriers to addressing perinatal depression, including lack of provider training, limited mental health resources,
and fears among women and providers.
• Identifies facilitators to perinatal depression treatment including validating and empowering interactions with health
care providers for women, obstetric provider training, standardized screening and referral processes, and improved
mental health resources.
• We critically reviewed clinical, programmatic, and systems level interventions regarding perinatal depression and based
on available literature, recommend changes at each level for optimization of recognition and treatment in obstetric
settings.

© 2012 Informa UK, Ltd.