Women’s Attitudes, Preferences, and Perceived Barriers to Treatment for Perinatal Depression

1. Women’s Attitudes, Preferences, and Perceived Barriers to Treatment for Perinatal Depression Janice H. Goodman, PhD.

2. Background of the research study: • “Perinatal depression is associated with potential negative consequences for the mother and infant, and therefore efforts to improve treatment access and efficacy are warranted” (1).

3. Facts about depression in females: • Women are twice as likely as men to experience depression during their lifetime • Childbearing women are at particularly high risk • Perinatal depression affects between 10% - 20% of women (with even higher rates among women of low socioeconomic status) • Perinatal depression can lead to a chronic or recurring depressive course throughout the woman’s life

4. Facts continue: • Several obstetric complications and adverse birth outcomes have been associated with depression during pregnancy • Antenatal depression is the greatest risk factor for postpartum depression, which can adversely affect mother-infant interaction, infant attachment, and child development

5. The most common barriers to mental health treatment in pregnant women • Stigma • Unacceptability of treatments • Financial barrier • Logistical barrier (lack of time, transportation, child care issues)

6. The depression treatment preferences • Couples counseling • Relaxation techniques • Exercise • Peer or family support • Self-care

7. Research study population: Data were collected from a convenience sample of 509 predominantly • Well-educated • High-income • Married woman in the northeastern United States during the last trimester of pregnancy

8. Variables of the study: • Age • Parity • Education • Race/ethnicity • Marital status • Employment • Income • Immigrant status • Primary language

9. Methods of collection: • Data were collected by means of questionnaire from a convenience sample of women recruited from the waiting rooms of two obstetrics clinics affiliated with a large urban teaching hospital in Boston, MA, from July 2006 through March 2007. • Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-rating scale developed to screen for depression in pregnant or postpartum women in community samples was used.

10. Eligibility for participation: Women were eligible for the study if: • They were in the third trimester of pregnancy • Were ages 18 years or above • Could read or speak English or Spanish

11. Questionnaire: The study questionnaire was used to collect the information about: • Demographics • History of depression • Past and current mental health symptoms • Past and current psychotropic use • Potential risk factors for depression during pregnancy (substance abuse, family history, social support)

12. Questionnaire:“Depression specific” question • “Have you ever had a period of 2 weeks or more when nearly every day you felt particularly sad, blue, or depressed or in which you lost all interest in things like work or social relationships?

13. Questionnaire:“Depression specific” question continue: Participants were supposed to indicate the time frame(s) of depression: • Before ever being pregnant • During a previous pregnancy • Within 6 months after a previous pregnancy • After a previous pregnancy but more than 6 months after delivery • During this pregnancy but not now • Currently

14. Edinburgh Postnatal Depression Scale (EPDS) • The scale focuses on cognitive and affective features of depression rather than somatic symptoms • It has been well validated for use in obstetric populations and has a validated Spanish language version • It has a satisfactory reliability and has adequate sensitivity and specificity when compared with a psychiatric diagnosis of major depression

15. Edinburgh Postnatal Depression Scale (EPDS) The authors of the EPDS recommend a cutoff score of: • 9/10 for minor depression • 12/13 for major postpartum depression

16. Other important parts of the questionnaire Assessment of: • Preference of depression treatment options • Stigma-related barriers • Attitudes towards psychotherapeutic and pharmacological treatments

17. Preference of depression treatment options • Individual psychotherapy • Medication • Family/couples therapy • Group therapy • Educational classes • Telephone support • Web- based internet support • Self-help materials • I’d rather wait to get over it on my own

18. Stigma-related barriers • Being embarrassed to talk about personal matters with others • Being afraid of what others might think • Family members might not approve

19. Attitudes towards psychotherapeutic and pharmacological treatments Attitudes were assessed by asking participants to respond to the following questions: • How acceptable is it to you to seek one-on-one counseling from a mental health professional for depression or anxiety? • How acceptable is it to you to seek group counseling for depression and anxiety? • How acceptable is it to you to take medication for depression or anxiety when pregnant?

20. Attitudes toward psychotherapeutic and pharmacological treatments continue: • How acceptable is it to you to take medication when breastfeeding? • How acceptable is it to you to take medication for depression or anxiety when neither pregnant or breastfeeding?

21. Results of the studySample description and mental health findings • A total of 525 women consented to take part in the study, with 509 completing the prenatal questionnaire • The mean age of participants was 31.6 years • 22% of participants reported significant levels of depressive symptoms • 8.6% fell into the probable depression range • 32.8% reported a previous history of depression • 14% of multiparas reported history of postpartum depression

22. Results of the studySample description and mental health findings continue: • 24% indicated that they thought that they needed help during sadness and depression • 21% reported having taking medication for depression in the past and/or currently, with 4.3% reporting current medication use • 34% reported past and/or current non-pharmacological help for depression, with 6.5% reporting current help • A total of 8.5% were receiving medication, non-pharmacological help, or both for depression at time of assessment

23. Results of the studyDepression treatment preferences, acceptability, and perceived barriers to treatment • 92% endorsed individual therapy • 62% indicated that group therapy was acceptable • Taking medication when neither pregnant nor breastfeeding was acceptable to 69%, compared to 33% when pregnant, and 35% when breastfeeding • 69.4% indicated that they would prefer to receive treatment at the obstetrics clinic • 22% reported preference to receive help from a mental health specialist at a mental health setting

24. Clinical implications • The current treatment recommendation for women who are experiencing depression during pregnancy or lactation is to carefully weigh the risks and benefits of various treatment options, and base decision on an individual woman’s health history, severity of depression, fetal gestational age or infant age, and treatment preferences.

25. Study strengths • Relatively large sample size • Diversity of participants • Exploration of preferences • Exploration of attitudes • Exploration of barriers to treatment

26. Study limitations • Results may not be generalizable to women in types of obstetrics practices other than large hospital-affiliated practices, or in geographically different locales • Because of demographic factors (well-educated, older, high socioeconomic status, and married), the results may not be generalizable to other populations.

27. Conclusion • The high prevalence of depression among pregnant women, and women’s perceived need for help for emotional distress, highlights the need to develop acceptable, accessibledepression interventions for diverse population of women

28. Conclusion • Understanding what prevents women from seeking or obtaining depression help, and determining what they prefer in the way of treatment, may lead to improved depression treatment rates and hold promise for improving the overall health of childbearing women

29. References • Goodman, J.H. (2009). Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth 36:1(March 2009).