General Hospital Psychiatry 79 (2022) 187–188
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General Hospital Psychiatry
journal homepage: www.elsevier.com/locate/genhospsych
Letter to the editor
Content and complexity of consultations in a provider-to-provider perinatal psychiatry
consultation line: A mixed methods analysis
Perinatal psychiatry consultation lines help prenatal and primary
care providers care for people with mental health needs related to
pregnancy and the first year postpartum [1–3]. These lines are respon­
sive to the vast unmet need for perinatal mental health treatment, the
scarcity of psychiatric providers trained in perinatal mental health, the
lack of comfort among many clinicians in managing perinatal mental
health and substance use disorders [4], and the need for consultation
and follow up in the context of recommendations for universal screening
for perinatal depression [5,6].
The Washington State Perinatal Psychiatry Consultation Line (Peri­
natal PCL, formerly known as Partnership Access Line (PAL for Moms) is
a free, state-funded program providing perinatal mental health consul­
tation and referrals for providers caring for pregnant or postpartum
patients. The program began in 2016 with philanthropic funding and
limited availability (weekdays 3 pm–5 pm). Since January 2019, Peri­
natal PCL has been state-funded and has expanded its hours and services.
Here, we describe the content and complexity of calls to the Perinatal
PCL and test our hypothesis that the complexity of consultation ques­
tions is increasing over time.
We employed deductive coding to analyze call summaries. We used
predefined category codes established based on AB, DC, CC, and KW (all
perinatal psychiatry consultants)’ review of consultation questions
regarding screening (S), diagnosis (D), medication (M), general inquiries
(G), resources or referral questions (R), and calls with no clear question
(NC). See Table 1 in the Appendix for details and examples.
Between 2016 and 2020 there were 844 consultation questions from
842 calls (two calls included two separate consultation questions which
were counted separately) from 438 unique callers. In the context of the
COVID-19 pandemic, average monthly calls increased from 24.6
(January 2019 through February 2020) to 37.3 (March through June
2020). Data beyond June 2020 are not included in the current analysis
since FK and MS completed their project and graduated, and given the
time then needed for coding, qualitative analysis and manuscript
development. The number of consultation questions by year was: 2016:
8% (n = 68), 2017: 10% (84), 2018: 19% (n = 160), 2019: 34% (n =
284), Jan-July 2020: 29% (n = 248). Prescribing providers (MD, DO,
ARNP) constituted 83.2% (n = 702) of callers. Others included non-
prescribing clinicians e.g., social workers and nurses (n = 124) or un­
known provider type (n = 16). Most questions concerned diagnosis (n =
348, 41.3%) or medications (n = 339, 40.2%). Others were general in­
quiries s (n = 19, 2.3%) questions about referrals (n = 109, 12.8%),
screening questions (6, 0.7%), or not coded due to insufficient infor­
mation (23, 2.7%). The number of calls per provider ranged from 1
through 24 (mean 2.4) with 454 providers calling once, and 151 calling
twice.
We evaluated complexity of the most frequent types of consultation
https://doi.org/10.1016/j.genhosppsych.2022.10.003
Received 30 August 2022; Received in revised form 30 September 2022; Accepted 5 October 2022
Available online 12 October 2022
0163-8343/© 2022 Elsevier Inc. All rights reserved.
questions (those concerning diagnosis and medication). For the 348
questions about diagnosis, most (195, 56%) were more complex, i.e.,
code complexity 3, 133 (38%) were of complexity 2, and the remainder
(20, 6%) code complexity 1. For the 339 medication questions, most
(145, 43%) were of code complexity 1, 124 (37%) code complexity 2,
and 70 (21%) code complexity 3. Overall call complexity increased over
the years as seen in Fig. 1.
A logistic regression revealed a significant main effect of year of call
(Wald x2 = 8.15, df = 1, p = .004), and of prescriber status, (Wald x2 =
17.13, df = 1, p = .000). According to the model, the more recent the
consultation question, the more likely it was to be of higher complexity
(and more so among prescribing providers).
We found that the utilization of the line increased steadily over time.
Callers included both prescribers and non-prescribers, attesting to the
usefulness of consultation lines for all clinicians who interact with
perinatal patients. The most common consultation questions were
around diagnosis and medication treatment, followed by referrals and
screening. This pattern is similar to that reported by other consultation
lines [1,7], and perhaps reflects the topic areas in which perinatal cli­
nicians require the most support. Questions about diagnosis tended to be
more complex and questions about medication less complex perhaps
because prenatal clinicians often need to make a preliminary diagnostic
assessment for their patients before determining the next best step in
management. The lower complexity of medication related questions
perhaps reflects the fact that prenatal clinicians refer patients to spe­
cialty mental health when they have more complex medication needs.
The complexity of calls increased over time, indicating that callers are
caring for increasingly complex psychiatric presentations in their peri­
natal patients. The reasons for this shift could include increased
awareness around perinatal mental health, availability and participation
in perinatal mental health trainings, and increases in callers’ knowledge
level, confidence, and motivation to care for patients with perinatal
mental health conditions as a result of consultation [8–10]. Limitations
of our study include inability to measure callers’ baseline knowledge in
perinatal mental health, or the increasing awareness and competence in
mental health among obstetric providers. The average monthly call
volume increased by 52% in the context of the COVID -19 pandemic.
Due to the sample size, we cannot determine whether this increase is
independent of the overall increase in call volume over time. We hope to
conduct such an analysis (including examination of change in code
complexity) in the future, with a larger dataset.
This study provides preliminary evidence of increasing utilization of
perinatal psychiatry consultation lines over time and increasing
complexity of consultations. Perinatal psychiatric consultants need to be
able to provide indirect psychiatric consultation on the diagnosis and
management of complex and co-occurring disorders in the perinatal
Letter to the editor
Fig. 1. Code complexity by year.
period. Several perinatal psychiatry access programs have developed a
process for one-time psychiatric evaluation of patients (by telemedicine
if needed) to provide recommendations for these complex cases. Addi­
tional supports such as social workers or behavioral health clinicians are
needed in all prenatal settings given the increasing complexity of pa­
tients in these settings.
Disclosures
None.
Acknowledgements
The Perinatal PCL line is funded by the WA State Health Care Au­
thority. The funding source had no role in study design, collection,
analysis and interpretation of data, writing of the report or decision to
submit the article for publication. We also acknowledge anonymous
donor funds, and we thank Matthew Hawrilenko, PhD and Joan Russo,
PhD for their input on the analytic plan.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.genhosppsych.2022.10.003.
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Amritha Bhata,*, Farah Khanb, Mariyam Shaikhc, Natalie Franzd,
Alicia Kerleea, Jamie Adachia, Carmen Croicua, Kelly Wurzele,
Deborah Cowleya
a
Department of Psychiatry and Behavioral Sciences, University of
Washington, Seattle, WA, United States of America
b
Committee for Children, NurtureNW, Seattle, WA, United States of
America
c
Department of Global Health, University of Washington, Seattle, WA,
United States of America
d
Washington State Department of Health, Tumwater, WA, United States of
America
e
Psychiatry Residency Spokane, Providence Sacred Heart Medical Center,
Spokane, WA, United States of America
*
Corresponding author at: 1959, NE Pacific Street, Box 356560,
Seattle, WA 98195, United States of America.
E-mail address: amritha@uw.edu (A. Bhat).