Integrated Behavioral Health Care in Reproductive Medicine: How and Why to Include Mental Health Professionals in Infertility Care Teams.

Despite fertility patients' reports of significant distress, few have access to integrated mental health care services. We elucidate the benefits and challenges of mental health integration in infertility practices from the perspective of both patients and providers. We outline specific models of integration, financial viability, and the first steps fertility clinics could take to improve their patients' access to these critical supports.

Prevention of perinatal depression with counseling in adolescents: a cost-effectiveness analysis.

OBJECTIVE: The US Preventive Services Task Force recently recommended that clinicians refer all pregnant and postpartum individuals at increased risk of perinatal depression to a counseling intervention. Adolescents are considered a high-risk group for perinatal depression. Therefore, we examined whether it is cost effective for all pregnant adolescents to be referred for preventive counseling. STUDY DESIGN: We developed a decision-analytic model using TreeAge Pro software to compare outcomes in pregnant adolescents who received versus did not receive counseling interventions. We used a theoretical cohort of 180,000 individuals, which is the estimated annual number of births to persons ≤ 19 years in the US. Outcomes included perinatal depression, chronic depression, maternal suicide attributed to depression, preterm delivery, neonatal death, cerebral palsy, and sudden infant death syndrome (SIDS), in addition to cost and quality-adjusted life years (QALYs). The willingness-to-pay (WTP) threshold was set to $100,000/QALY. We derived model inputs from the literature, and sensitivity analyses were used to assess robustness of the model. RESULTS: A strategy of referral to counseling interventions was cost effective in our theoretical cohort, with 8935 fewer cases of perinatal depression, 1606 fewer cases of chronic depression, 166 fewer preterm deliveries, 4 fewer neonatal deaths, 1 fewer case of cerebral palsy, 20 fewer cases of SIDS. In total, there were 21,976 additional QALYs and cost savings of $223,549,872, making it the dominant strategy (better outcomes with lower costs). We found that counseling interventions remained cost saving until the annual direct and indirect cost of chronic, severe depression was set below $30,000, at which point it became cost effective (baseline input: $182,309). CONCLUSION: We found it was cost effective to refer all pregnant adolescents for preventive counseling interventions. Clinicians should develop approaches to identify and refer pregnant adolescents for behavioral counseling to prevent perinatal depression.

Perinatal Loss: The Impact on Maternal Mental Health.

IMPORTANCE: Psychological reactions to perinatal loss, although often self-limited, may lead to significant psychological morbidities. Obstetrician-gynecologists and other maternal health providers play a key role in recognizing the range of psychological responses to perinatal loss and providing education, support, and treatment options to their patients. OBJECTIVE: This review aims to define psychological reactions associated with perinatal loss, examine psychotherapy and psychopharmacologic treatments for psychiatric morbidities, discuss interpregnancy interval following perinatal loss, and highlight brief, psychological interventions that can be implemented by maternal health providers. EVIDENCE ACQUISITION: Search terms "perinatal loss psychology," "reproductive loss grief," "perinatal psychopharmacology," "psychopharmacology grief," and "interpregnancy interval" were utilized to search PubMed, Google Scholar, and PsycINFO. RESULTS: Grief is an expected, normal response to perinatal loss. Psychological morbidities, including major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder, are also associated with perinatal loss. Risk factors for these conditions include history of a psychiatric illness, childlessness, unknown cause of perinatal loss, limited social support, and marital/relationship discord. Careful interviewing and brief screening measures can help identify patients who may suffer from depressive or anxiety disorders following reproductive loss. Patients with perinatal loss can benefit from psychological and possibly pharmacologic treatments. Recommended interpregnancy interval after perinatal loss should be customized by gestational age and cause of loss. CONCLUSIONS AND RELEVANCE: Patients with perinatal loss emotionally benefit from their reproductive health care providers acknowledging the psychological aspects of reproductive loss, inquiring about their emotional needs, and providing information regarding grief and mental health referrals.

Perinatal Posttraumatic Stress Disorder: A Review of Risk Factors, Diagnosis, and Treatment.

IMPORTANCE: Perinatal posttraumatic stress disorder (P-PTSD) occurs in approximately 3% to 15% of women in the postpartum period. It is often underrecognized, poorly characterized, and undertreated. If untreated, it can lead to maternal and infant morbidity. OBJECTIVE: The aim of this review article is to discuss P-PTSD as it relates to the obstetrician gynecologist, focusing specifically on identifying perinatal risk factors, P-PTSD diagnostic tools, and treatment options. EVIDENCE ACQUISITION: PubMed, PsycINFO, Cochrane Library, and Scopus were searched on MeSH terms and free text for terms related specifically to P-PTSD. Because of the lack of data on treatment specifically for the perinatal population, a second search for general PTSD treatment guidelines was conducted and incorporated into this review. RESULTS: Risk factors have been identified in the literature in 4 major categories: obstetric, psychiatric, social, and subjective distress during delivery. Two diagnostic tests, the general PTSD diagnostic tool, the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the specific diagnostic tool, the Perinatal Post-Traumatic Stress Disorder Questionnaire, can both be helpful for the clinician to diagnose patients who may have P-PTSD. Individual trauma-focused psychotherapy is first line for treatment of P-PTSD. Immediate debriefing interventions and non-trauma-focused psychotherapy has not been shown to be helpful. If trauma-focused psychotherapy is not available or not preferred, selective serotonin reuptake inhibitors and non-trauma-focused psychotherapy can be used. CONCLUSIONS AND RELEVANCE: When designing and carrying out the program, the beginning of the intervention and adherence should be considered. To increase adherence, the program should be attractive and it should meet the participants' needs. CONCLUSIONS AND RELEVANCE: Identifying and treating P-PTSD have important implications for maternal and neonatal health. Few treatment studies exist for P-PTSD specifically, so combining P-PTSD research with current guidelines for PTSD is necessary to inform clinical practice.

Mindfulness-Based Group Cognitive Behavior Therapy for Provoked Localized Vulvodynia: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the effectiveness of mindfulness-based group cognitive behavior therapy (M-gCBT) versus education support group therapy for the pain and distress associated with provoked localized vulvodynia. MATERIALS AND METHODS: Participants were randomized to M-gCBT or education support group therapy. Mindfulness-based group cognitive behavior participants attended 8 weekly sessions. Education support group participants received 8 weeks of online education with 3 in-person group visits. Vaginal insertion pain (tampon test) was the primary outcome. Secondary outcomes (Generalized Anxiety Disorder 7, Beck's Depression Index, Female Sexual Distress Scale, Female Sexual Function Index, and Pain Catastrophizing) were administered before intervention and at the completion of the study period, 3 months, and 6 months. Sample size was based on the ideal number for group dynamics of 6 to 12 participants per group. RESULTS: Participants were enrolled from August 1, 2016, to January 30, 2017. Thirty-two participants were enrolled and 31 were randomized: 14 to M-gCBT and 17 to education support. Baseline characteristics did not differ significantly. Vaginal insertion pain decreased in both groups but was not statistically different between groups (difference of 1.23; 95% CI = -0.52 to 2.98). At 6 months, participants in the M-gCBT group showed statistically significant improvement in the Female Sexual Function Index, Generalized Anxiety Disorder 7, and Beck's Depression Index compared with the education support group. CONCLUSIONS: Mindfulness-based group cognitive behavior and education support group therapy are effective in reducing pain and distress. However, women in the M-gCBT program showed greater improvement in certain secondary outcomes, indicating that M-gCBT may offer some advantages in reducing distress associated with provoked localized vulvodynia.