Screening, Assessment, and Treatment of Perinatal Mental Health in Obstetrical Settings.

Perinatal mood and anxiety disorders (PMADs) are common, yet obstetricians receive little training prior to independent practice on screening, assessing, diagnosing, and treating patients with depression and anxiety. Untreated PMADs lead to adverse pregnancy and fetal outcomes. Obstetricians are in a unique position to address PMADs. The following serves as a resource for addressing PMADs in obstetric practice.

The Pressing Need to Integrate Mental Health into Obstetric Care.

Mental health and substance use conditions are prevalent among perinatal individuals. These conditions have a negative impact on the health of perinatal individuals, their infants, and families, yet are underdiagnosed and undertreated. Populations that have been marginalized disproportionately face barriers to accessing care. Integrating mental health into obstetric care could address the perinatal mental health crisis. We review perinatal mental health conditions and substance use, outline the impact associated with these conditions, and describe the promise and potential of integrating mental health into obstetric settings to improve outcomes for patients receiving obstetric and gynecologic care.

A Qualitative Investigation of the Experiences of Women with Perinatal Depression and Anxiety during the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic has had significant impacts on maternal mental health. We explored the lived experiences of women with perinatal depression and anxiety to elucidate their perceptions of how the pandemic influenced their mental health and access to care. METHODS: We conducted a qualitative descriptive study using semi-structured interviews. From March to October 2021, purposive sampling was used to recruit a socio-demographically diverse sample of women with self-reported perinatal depression or anxiety who were pregnant or within one year postpartum between March 2020 and October 2021. Interviews were conducted remotely and thematically analyzed. RESULTS: Fourteen women were interviewed. Three major themes arose. Theme 1, Negative impacts of COVID-19 on symptoms of depression and anxiety, described how the pandemic magnified underlying symptoms of depression and anxiety, increased social isolation, generated anxiety due to fears of COVID-19 infection, and caused economic stress. In theme 2, Negative impacts of COVID-19 on access to and quality of health care, women described stressful and isolating delivery experiences, negative psychological impact of partners not being able to participate in their perinatal health care, interruptions and barriers to mental health treatment, and challenges in using telehealth services for mental health care. Theme 3, Positive impacts of COVID-19 on mental health, identified advantages of increased telehealth access and ability to work and study from home. CONCLUSIONS FOR PRACTICE: The COVID-19 pandemic negatively affected women with perinatal depression and anxiety by magnifying underlying symptoms, increasing stress and social isolation, and disrupting access to mental health care. Findings provide support for policies and interventions to prevent and address social isolation, as well as optimization of telehealth services to prevent and address gaps in perinatal mental health treatment.

Improving front-line clinician capacity to address depression and bipolar disorder among perinatal individuals: a longitudinal analysis of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms.

Perinatal mood disorders (PMDs) are common, yet many patients are undertreated. The Massachusetts Child Psychiatry Access Program (MCPAP) for Moms is designed to increase clinicians' willingness to address PMDs. We examined utilization of MCPAP for Moms and associations with PMDs treatment, including the more complex bipolar disorder (BD). Analyses of MCPAP for Moms data examined utilization from 7/2014 to 6/2020 and associated treatment outcomes. Participants were clinicians (n = 1006) in obstetrics/gynecology, family medicine, and pediatrics. Encounters included (1) resource and referrals and (2) psychiatric consultations (program psychiatrist consultation with clinicians or patients). Utilization sub-groups were identified using group-based trajectory modeling. Higher utilization of MCPAP for Moms was associated with increased rates of treating PMDs (incidence rate ratio [IRR] = 1.07, 95% CI: 1.06-1.07). Examining by encounter type, psychiatric consultations resulted in more frequent rates of clinicians treating PMDs than resource and referral encounters. Utilization of direct patient consultation was associated with the greatest increase in rates of clinicians treating BD (IRR = 2.12, 95% CI: 1.82-2.41). Clinicians with highest utilization rates of psychiatric consultations longitudinally had strongest predictive associations with providing direct mental healthcare to patients with BD (IRR = 13.5, 95% CI: 4.2-43.2). Utilization of MCPAP for Moms facilitates clinicians' ability to provide mental health treatment to patients.

Labor and Delivery Clinician Perspectives on Impact of Traumatic Clinical Experiences and Need for Systemic Supports.

OBJECTIVES: Few studies have elucidated the impact of work-related trauma on labor and delivery clinician or considered whether it may be a cause of burnout. This study aims to elicit labor and delivery clinician perspectives on the impact of exposure to traumatic births on their professional quality of life. METHODS: Labor and delivery clinicians (physicians, midwives, nurse practitioners, and nurses; n = 165) were recruited to complete an online questionnaire on experiences with traumatic births. The questionnaire contained measures from the Maslach Burnout Inventory and the professional quality of life scale version 5. Some participants completed an optional free-text prompt to recommend ways to support clinicians after traumatic births (n = 115). Others opted into a semi-structured phone interview (n = 8). Qualitative data was analyzed using a modified grounded theory approach. RESULTS: Self-reported adequate institutional support for clinicians after a traumatic birth was positively correlated with compassion satisfaction (r = 0.21, p < 0.01) and negatively correlated with secondary traumatic stress (r = - 0.27, p < 0.01), and burnout (r = - 0.26, p < 0.01). Qualitative themes included lack of system-wide and leadership support, lack of access to mental health resources, and suboptimal workplace culture as contributors toward secondary traumatic stress and burnout. Participants recommended proactive leadership, consistent debriefing protocols, trauma education, and improved access to counseling. CONCLUSIONS FOR PRACTICE: Multi-level barriers prevented labor and delivery clinicians from accessing needed mental health support after exposure to traumatic births. Proactive investment in healthcare system supports for clinicians may improve clinician professional quality of life.

Parental substance use and home visiting programs: Implementation considerations for relationship-based treatment.

Home visiting programs can provide critical support to mothers in recovery from substance use disorders (SUDs) and young children prenatally exposed to substances. However, families impacted by maternal SUDs may not benefit from traditional child-focused developmental home visiting services as much as families not impacted by SUDs, suggesting the need to adjust service provision for this population. Given the need to implement tailored services within home visiting programs for families impacted by SUDs, we sought to investigate the implementation barriers and facilitators to inform future integration of a relationship-based parenting intervention developed specifically for parents with SUDs (Mothering from the Inside Out) into home visiting programs. We conducted nine interviews and five focus groups with a racially diverse sample (N = 38) of parents and providers delivering services for families affected by SUDs in the USA. Qualitative content analysis yielded three most prominent themes related to separate implementation domains and their associated barriers and facilitators: (1) engagement, (2) training, and (3) sustainability. We concluded that the home visiting setting may mitigate the logistical barriers to access for families affected by SUDs, whereas relationship-based services may mitigate the emotional barriers that parents with SUDs experience when referred to home visiting programs.

Los programas de visita a casa pueden ofrecer un apoyo clave a madres en recuperación de trastornos por abusos de sustancias (SUD) y los niños pequeños expuestos a sustancia prenatalmente. Sin embargo, las familias que recibieron el impacto de SUD materno pudieran no beneficiarse de los servicios tradicionales de visita a casa en cuanto al desarrollo enfocados en el niño tanto como las familias que no sufren el impacto de SDU, lo cual sugiere la necesidad de ajustar el ofrecimiento de servicios para este grupo de población. Dada la necesidad de implementar servicios amoldados dentro de los programas de visita a casa para familias que sufren el impacto de SUD, nos propusimos investigar las barreras y los aspectos que facilitan la implementación a manera de informar la futura integración de una intervención de crianza con base en la relación, específicamente desarrollada para progenitores con SUD (Cuidados Maternales Desde Dentro) en los programas de visita a casa. Llevamos a cabo nueve entrevistas y cinco grupos de enfoque con un grupo muestra racialmente diverso (N = 38) de progenitores y proveedores que ofrecen los servicios a familias que sufren el impacto de SUD en los Estados Unidos. Los análisis de contenido cualitativo arrojaron tres temas más prominentes relacionados con dominios de implementación separados y las asociadas barreras y aspectos que la facilitan: (1) involucramiento, (2) entrenamiento, y (3) sostenibilidad. Concluimos que el escenario de visita a casa pudiera mitigar las barreras logísticas de acceso para familias afectadas por SUD, mientras que los servicios con base en la relación pudieran mitigar las barreras emocionales que los progenitores con SUD experimentan cuando se les refiere a programas de visita a casa.

Les programmes de visite à domicile peuvent offrir un soutien critique aux mères qui se rétablissent d'un trouble lié à l'usage d'une substance (TUS) et aux jeunes enfants exposés à des substances avant leur naissance. Cependant les familles impactées par des TUS maternels ne bénéficient pas de services de visite à domicile traditionnels autant que des familles non impactées par un TUS, suggérant le besoin d'ajuster des prestations de service pour cette population. Vu le besoin de mettre en place des services adaptés au sein des programmes de visite à domicile pour les familles impactées par des TUS, nous avons décidé d'étudier les barrières et les facteurs de facilitation de mise en place afin d'éclairer l'intégration future d'une intervention de parentage basée sur une relation développée spécifiquement pour des parents avec des TUS (le maternage de l'intérieur suivant l'anglais Mothering from the Inside Out) dans des programmes de visite à domicile. Nous avons procédé à neuf entretiens et cinq groupes d'étude avec un échantille variés du point de vue racial (N = 38) de parents et de prestataires offrant des services pour des familles affectées par des TUS aux Etats-Unis d'Amérique. Une analyse qualitative de contenu a donné trois groupes importants lié à des domaines de mise en place séparés et les barrières et facteurs de facilitation y étant liés: (1) l'engagement, (2) la formation, et (3) la durabilité. Nous concluons que le contexte de visite à domicile peut mitiger les barrières logistiques à l'accès pour les familles affectées par des TUS, alors que les services relationnels peuvent mitiger les barrières émotionnelles dont les parents avec des TUS font l'expérience lorsqu'on leur recommande des programmes de visite à domicile.

How to Mitigate Risk of Premature Cardiovascular Disease Among Children and Adolescents with Mental Health Conditions.

PURPOSE OF REVIEW: The goal of this article is to characterize the myriad of ways that children with mental health conditions can be at risk for premature cardiovascular disease (CVD) and various modalities to ameliorate this risk in childhood in order to improve the life course of these children. REVIEW FINDINGS: Child and adolescent mental health conditions are a common yet underrecognized risk factor for premature CVD. The American Heart Association has recently included psychiatric conditions as a CVD risk factor (CVDRF) and the evidence linking childhood adversity to cardiometabolic disease. There are bidirectional and additive effects from the intrinsic emotional dysregulation and inflammatory changes from the mental health condition, the associations with risky health behaviors, and in some cases, metabolic side effects from pharmacotherapy. These pathways can be potentiated by toxic stress, a physiologic response to stressors from childhood adversity. Toxic stress is also associated with development of mental health conditions with epigenetic effects that can result in transgenerational inheritance of cardiometabolic risk. Exposure to toxic stress and mental health conditions in isolation sometimes compounded by pharmacotherapies used in treatment increase the risk of cardiometabolic diseases in childhood. The multiple pathways, which adversely influence cardiometabolic outcomes, encourage clinicians to consider strategies to mitigate these factors and justify the importance of early screening and treatment for CVDRFs. Mental health, health behaviors, and environmental factors co-occur and intersect in complex pathways that can increase CVD risk over the lifespan. Early detection and response can mitigate the risks associated with premature development of CVD.

Trauma-Informed Care for Obstetric and Gynecologic Settings.

PURPOSE: Trauma is common among those seeking Ob-Gyn care and may have pervasive impact on obstetrical and gynecological health, social functioning, and healthcare engagement. While guidelines exist on the detection and treatment of perinatal mood and anxiety disorders within Ob-Gyn care, the role of Ob-gyn clinicians in identifying and addressing patients' traumatic experiences and related symptoms is less clearly delineated. This manuscript provides an overview of trauma-related symptoms in the context of Ob-Gyn care and practical guidance of clinicians aiming to improve their detection and response to trauma in their clinical practice. DESCRIPTION: Posttraumatic stress disorder (PTSD) describes a psychiatric illness which develops as a response to a traumatic event. Women who have experienced trauma are also at increased risk for borderline personality disorder and other psychiatric comorbidities. Postpartum PTSD has particular relevance to obstetrical care. ASSESSMENT: Screening for trauma in Ob-Gyn care can provide an opportunity to address risk and offer targeted intervention. Several brief evidence-based screening tools are available. Individuals who screen positive require assessment of immediate safety and targeted referrals. Trauma informed care describes an approach to healthcare aimed to enhance physical and emotional safety for patients and clinicians. CONCLUSION: Given the prevalence and the potentially devastating and enduring impact of trauma and trauma-related symptoms, there is a critical need to address trauma within Ob-Gyn care. By recognizing the signs of trauma and initiating or referring to appropriate treatments, Ob-Gyn clinicians have a unique opportunity to better understand their patients and to improve their care.

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

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

Self-Reported Causes of Psychological Distress Among Czech Perinatal Women.

BACKGROUND: Various risk factors to perinatal mental health disorders have been described; however, there is a dearth of data on the perspectives of women themselves regarding what increases the risk of psychological distress. This qualitative study explores women's perceptions of factors that increase the risk of perinatal psychological distress. AIM: The aim of this study was to elucidate women's perceptions of factors that increase the risk of perinatal psychological distress. METHODS: A qualitative design with an exploratory and descriptive approach is used. Women (N = 188) aged 18 to 45 years who self-report experiencing perinatal psychological distress complete an online survey. RESULTS: Perceived causes of perinatal psychological distress include: adverse experiences with childbirth and/or breastfeeding, negative attitudes of people close to the participant, financial and social challenges, health challenges, staff behavior in a maternity hospital, a challenging baby, family circumstances, and the new role as mother. CONCLUSION: Women's perceived causes of perinatal psychological distress may allow for women-centered innovations in perinatal mental health care. The results highlight the need to train maternity staff regarding perinatal mental health and communication. These findings can serve as important guidelines on women-centered planning of innovations of perinatal mental health care. Interventions need to focus on the role of partners and others close to women so as to support the women during the perinatal period.

Engagement in perinatal outpatient services among women in recovery from opioid use disorders.

Background: Despite being highly motivated to recover, pregnant and postpartum women with opioid use disorders (OUD) are at high risk of relapse and death. While many services mitigate this risk, engagement in voluntary, outpatient services remains low. Our aim was to understand the experiences of and factors influencing outpatient service engagement during the perinatal period among women in recovery from OUD. Methods: We conducted semi-structured interviews about perinatal experiences engaging with outpatient services, with 20 women in recovery aged 22-46 years who had children between 6 months and 10 years old. Interviews were audio-recorded, transcribed, coded, and analyzed using conventional content analysis. Results: Women described a continuum of 'collaborative engagement' experiences, defined by the extent to which they perceived their providers or service organizations were invested in their journeys as a partners and advocates. The ability to achieve collaborative engagement depended upon two factors: (1) the woman's transformational development as a mother and woman in recovery, and (2) her perception of the providers' ability to meet her multifaceted needs. Conclusions: Women in recovery from OUD may experience deeper engagement in voluntary outpatient perinatal services when they perceive that their providers are invested and collaboratively engaging in their recovery and personal growth. Future research should test whether collaborative engagement improves service retention.Abbreviations: IPV: Intimate Partner Violence; OUD: opioid use disorder.

Screening for Mental Health and Substance Use Disorders in Obstetric Settings.

PURPOSE OF REVIEW: The objective of this review is to describe the extent to which (1) obstetric settings are currently screening for mental health and substance use disorders and social determinants of health (SDoH), and (2) screening is followed by systematic approaches for ensuring an adequate response to positive screens. Additionally, clinical and policy implications of current screening practices and recommendations are discussed. RECENT FINDINGS: Screening for perinatal depression in obstetric settings has increased. Despite their prevalence and negative impact, screening for other mental health and substance use disorders and SDoH is much less common and professional society recommendations are either nonexistent, less consistent, or less prescriptive. To truly address maternal mental health, we need to move beyond focusing solely on depression and address other mental health and substance use disorders and the contextual social determinants in which they occur.

The PRogram In Support of Moms (PRISM): study protocol for a cluster randomized controlled trial of two active interventions addressing perinatal depression in obstetric settings.

BACKGROUND: Perinatal depression, the most common pregnancy complication, is associated with negative maternal-offspring outcomes. Despite existence of effective treatments, it is under-recognized and under-treated. Professional organizations recommend universal screening, yet multi-level barriers exist to ensuring effective diagnosis, treatment, and follow-up. Integrating mental health and obstetric care holds significant promise for addressing perinatal depression. The overall study goal is to compare the effectiveness of two active interventions: (1) the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, a state-wide, population-based program, and (2) the PRogram In Support of Moms (PRISM) which includes MCPAP for Moms plus a proactive, multifaceted, practice-level intervention with intensive implementation support. METHODS: This study is conducted in two phases: (1) a run-in phase which has been completed and involved practice and patient participant recruitment to demonstrate feasibility for the second phase, and (2) a cluster randomized controlled trial (RCT), which is ongoing, and will compare two active interventions 1:1 with ten Ob/Gyn practices as the unit of randomization. In phase 1, rates of depressive symptoms and other demographic and clinical features among patients were examined to inform practice randomization. Patient participants to be recruited in phase 2 will be followed longitudinally until 13 months postpartum; they will have 3-5 total study visits depending on whether their initial recruitment and interview was at 4-24 or 32-40 weeks gestation, or 1-3 months postpartum. Sampling throughout pregnancy and postpartum will ensure participants with different depressive symptom onset times. Differences in depression symptomatology and treatment participation will be compared between patient participants by intervention arm. DISCUSSION: This manuscript describes the full two-phase study protocol. The study design is innovative because it combines effectiveness with implementation research designs and integrates critical components of participatory action research. Our approach assesses the feasibility, acceptance, efficacy, and sustainability of integrating a stepped-care approach to perinatal depression care into ambulatory obstetric settings; an approach that is flexible and can be tailored and adapted to fit unique workflows of real-world practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02760004, registered prospectively on May 3, 2016.

Perinatal depression care pathway for obstetric settings.

Perinatal depression is common and can have deleterious effects on mothers, infants, children, partners, and families. Despite this, few women who screen positive for depression receive psychiatric treatment. A comprehensive perinatal depression care pathway includes: (1) screening, (2) assessment, (3) triage and referral, (4) treatment access, (5) treatment initiation, (6) symptom monitoring, and (7) adaptation of treatment based on measurement until symptoms remit. This depression care pathway provides a scaffold on which to frame the challenges encountered when, and the opportunities that exist for, addressing depression in obstetric settings. Comprehensive interventions that address each step on the care pathway are needed to support obstetric practices in providing high-quality, evidence-based, effective treatment including pro-active follow-up for depression management. Despite recent attention being brought to, and significant progress in the field of maternal mental health, gaps in care persist. Ultimately, depression care needs to be fully integrated into obstetric care. Additionally, more targeted maternal mental health support and structure are needed for integration to occur and ultimately be optimized. Specific areas requiring more attention include consistency of screening, evaluation of patients with a positive depression screen for bipolar disorder, anxiety or substance use disorders, and monitoring of symptom improvement.

School nurse asthma program reduces healthcare utilization in children with persistent asthma.

OBJECTIVE: We examined the impact of a novel, school nurse-supervised asthma therapy program on healthcare utilization. METHODS: We retrospectively reviewed charts of 84 children enrolled in this program in central Massachusetts between 2012 and 2015. Physicians identified children with persistent asthma and poor medication adherence. These children were enrolled in the program to receive daily-inhaled corticosteroid at school, supervised by their school nurse, with ongoing communication between physician's office and school nurse through the school year. This program relied on established family, provider and school resources rather than research staff. The primary outcome was change in the number of emergency department (ED) visits in the year before and after enrollment. Secondary outcomes were hospital admissions, school absences, and rescue medication use. RESULTS: The study population was on average 10.5 years old, 63% male, 67% Hispanic, 19% black, 14% white with 95% using Medicaid insurance. Asthma-related ED visits over a 1-year period decreased 37.5%, from a pre-intervention mean of 0.8 visits to a post-intervention mean of 0.3 visits (p < 0.001). Asthma-related hospital admissions decreased from a pre-intervention mean of 0.3 admissions to post-intervention mean of 0 admissions (p < 0.001). Asthma rescue medication refills decreased by 46.3% from the pre- to post-intervention period (p = <.001). There were also non-significant declines in school absences and oral steroid use for children enrolled. CONCLUSIONS: We demonstrate a significant reduction in healthcare utilization for children enrolled in this unique school nurse-supervised asthma program, which utilizes a clinical-school partnership to deliver preventative asthma medication to school-aged children under sustainable conditions.

How obstetric settings can help address gaps in psychiatric care for pregnant and postpartum women with bipolar disorder.

To elucidate (1) the challenges associated with under-recognition of bipolar disorder in obstetric settings, (2) barriers pregnant and postpartum women with bipolar disorder face when trying to access psychiatric care, and (3) how obstetric settings can identify such women and connect them with mental health services. Structured, in-depth interviews were conducted with 25 pregnant and postpartum women recruited from obstetric practices who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II, or not otherwise specified using the Mini International Neuropsychiatric Interview. Quantitative analyses included descriptive statistics. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach. Most participants (n = 19, 79.17%) did not have a clinical diagnosis of bipolar disorder documented in their medical records nor had received referral for treatment during pregnancy (n = 15, 60%). Of participants receiving pharmacotherapy (n = 14, 58.33%), most were treated with an antidepressant alone (n = 10, 71.42%). Most medication was prescribed by an obstetric (n = 4, 28.57%) or primary care provider (n = 7, 50%). Qualitative interviews indicated that participants want their obstetric practices to proactively screen for, discuss and help them obtain mental health treatment. Women face challenges in securing mental health treatment appropriate to their bipolar illness. Obstetric providers provide the bulk of medical care for these women and need supports in place to (1) better recognize bipolar disorder, (2) avoid inappropriate prescribing practices for women with undiagnosed bipolar disorder, and (3) ensure women are referred to specialized treatment when needed.

Caste matters: perceived discrimination among women in rural India.

The aim of this study is to examine the relationship of caste and class with perceived discrimination among pregnant women from rural western India. A cross-sectional survey was administered to 170 pregnant women in rural Gujarat, India, who were enrolled in a longitudinal cohort study. The Everyday Discrimination Scale and the Experiences of Discrimination questionnaires were used to assess perceived discrimination and response to discrimination. Based on self-report caste, women were classified into three categories with increasing historical disadvantage: General, Other Backward Castes (OBC), and Scheduled Caste or Tribes (SC/ST). Socioeconomic class was determined using the standardized Kuppuswamy scale. Regression models for count and binomial data were used to examine association of caste and class with experience of discrimination and response to discrimination. Sixty-eight percent of women experienced discrimination. After adjusting for confounders, there was a consistent trend and association of discrimination with caste but not class. In comparison to General Caste, lower caste (OBC, SC/ST) women were more likely to (1) experience discrimination (OBC OR: 2.2, SC/ST: 4.1; p trend: 0.01); (2) have a greater perceived discrimination score (OBC IRR: 1.3, SC/ST: 1.5; p trend: 0.07); (3) accept discrimination (OBC OR: 6.4, SC/ST: 7.6; p trend: < 0.01); and (4) keep to herself about discrimination (OBC OR: 2.7, SC/ST: 3.6; p trend: 0.04). The differential experience of discrimination by lower caste pregnant women in comparison to upper caste pregnant women and their response to such experiences highlight the importance of studying discrimination to understand the root causes of existing caste-based disparities.

A Systematic Review of Integrated Care Interventions Addressing Perinatal Depression Care in Ambulatory Obstetric Care Settings.

This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.

Postpartum Depression-New Screening Recommendations and Treatments.

This Insights in the Women's Health series describes perinatal depression (occurring prepregnancy through postpartum periods) and new recommendations and treatment guidelines for this condition.