Opening the door: midwives' perceptions of two models of psychosocial assessment in pregnancy- a mixed methods study.

BACKGROUND: One in five women experience psychological distress in the perinatal period. To support women appropriately, Australian guidelines recommend routine depression screening and psychosocial risk assessment by midwives in pregnancy. However, there is some evidence that current screening processes results in higher rates of false positives. The Perinatal Integrated Psychosocial Assessment (PIPA) Project compared two models of psychosocial assessment and referral - Usual Care and the PIPA model - with a view to improving referral decisions. This paper describes midwives' perspectives on psychosocial assessment, depression screening and referral at the antenatal booking appointment and compares midwives' experiences with, and perspectives on, the two models of care under investigation. METHODS: A two-phase, convergent mixed methods design was used. Midwives providing antenatal care completed a self-report survey in phase one prior to implementation of the new model of psychosocial assessment (n = 26) and again in phase two, following implementation (n = 27). Sixteen midwives also participated in two focus groups in phase two. Quantitative and qualitative data were compared and integrated in the presentation of results and interpretation of findings. RESULTS: Midwives supported psychosocial assessment believing it was a catalyst for 'Opening the door" to conversations with women. Midwives were comfortable asking the questions and tailored their approach to build rapport and trust. Overall. midwives expressed favourable views towards the PIPA model. A greater proportion of midwives relied mostly or entirely on the suggested wording for the psychosocial questions in the PIPA model compared to Usual Care (44.4% vs 12.0%, χ2=5.17, p=.023, φ =-.36). All midwives reported finding the referral or action message displayed at the end of the PIPA psychosocial assessment to be 'somewhat' or 'very' helpful, compared to 42.3% in Usual Care (χ2 = 18.36, p < .001, φ = -.64). Midwives were also more likely to act on or implement the message often or all of the time) in the PIPA model (PIPA = 69.2% vs Usual Care = 32.0%, (χ2 = 5.66, p < .017, φ = -.37). CONCLUSION: The study identified benefits of the new model and can inform improvements in psychosocial screening, referral and related care processes within maternity settings. The study demonstrates that psychosocial assessment can, over time, become normalised and embedded in practice.

Health professional's knowledge and awareness of perinatal depression: results of a national survey.

INTRODUCTION: Postnatal depression affects 14% of women, occurring also antenatally, with potential long-term consequences, making it an important disorder to detect and manage early. In this study we sought to examine knowledge and awareness of perinatal depression in health professionals involved in perinatal care throughout Australia prior to the implementation of a comprehensive screening program, aimed at improving detection and access to appropriate management. METHODS: A random sample of General Practitioners (GPs) and Maternal Child Health Nurses (MCHNs) and Midwives, in regions throughout Australia to be subsequently targeted by a screening and education program, were invited to participate. Responses to a hypothetical vignette and a knowledge questionnaire, as well as details of experience were completed. FINDINGS: Questionnaires were completed by 246 GPs, 338 MCHNs and 569 midwives, with overall response rates; GP's 23%; MCHN's 55% and midwives 57%. Although knowledge level was similar among professional groups, MCHNs had higher levels of awareness of perinatal depression. Both GPs and MCHNs were more likely than midwives to recognize the need for providing help to women with emotional distress. Depression was more likely to be considered postnatally than antenatally in all groups, with GPs most likely to provide this diagnosis. GPs had a significant propensity to recommend antidepressants, and midwives to select non-specific medications. CONCLUSIONS: Health professionals responding to this survey had a high awareness and similar knowledge base. Further education on antenatal depression and the safety risks and alternatives to medication is important for all groups, but particularly important for midwives and GPs. The latter is especially relevant given the preference for women with perinatal depression not to use pharmacological interventions to treat their emotional distress.

Actions taken to cope with depression in patients seeking specialist care.

OBJECTIVE: To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression. METHOD: One hundred and seventy-six patients (74 male, 102 female) aged 16-82 years (M = 42, SD = 14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression. RESULTS: Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness. CONCLUSION: A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies.

Use of psychotropic medications in breast-feeding women: acute and prophylactic treatment.

OBJECTIVES: The postnatal period is a time of increased onset and relapse of mental illness. It poses a clinical dilemma, as many mothers requiring medication acutely or prophylactically will also choose to breast feed. The present paper first reviews the safety of psychotropes in breast-fed infants and the usefulness of prophylaxis for women at risk of postpartum affective relapse and, second, provides guidelines in the use of psychotropic drugs in breast-feeding women. METHODS: A Medline review was conducted reviewing all papers published during the period 1993-1998 (and their associated bibliographies) on the use of psychotropes in breast-feeding women and the prophylactic usefulness of medications in women at risk of affective postpartum relapse. RESULTS: Findings are based on case reports and small, mostly uncontrolled studies. Both tricyclic antidepressants (TCA) and specific serotonin re-uptake inhibitors (SSRIs) appear to be relatively safe in breast feeding. Antidepressants commenced in the early postpartum period may reduce depressive relapse. While prophylactic lithium appears to significantly reduce relapse of affective psychosis in the puerperium, there have been no studies of the anticonvulsants in the puerperium. Finally, high dose antipsychotics should be avoided, as they may be associated with long-term adverse sequelae in the infant. CONCLUSIONS: On the basis of current knowledge, the use of SSRIs, TCA, carbamazepine, sodium valproate and short-acting benzodiazepines in breast feeding is relatively safe. If lithium is to be used, close collaboration with a paediatrician is essential. The long-term risks of antipsychotics, especially at high doses, remain to be clarified. Before a decision can be made, the risk-benefit ratio must be clearly outlined and discussed with the mother and her partner.

Proactive interference and the neuropsychology of schizophrenia.

Gray, Felden, Rawlins, Hemsley & Smith (1991) have proposed a theoretical model of the neuropsychology of schizophrenia. A major feature of this model is that it is a weakening of the influences of memories of previous input on current perception/learning which is basic to the phenomenon of acute schizophrenia. In the present study, proactive interference (PI) was used as a paradigm to test this hypothesis. PI occurs when new learning is diminished as a consequence of previously learned material. According to our reading of the Gray et al. (1991) model, acutely ill unmedicated patients with schizophrenia should demonstrate reduced PI relative to controls. Ten acutely ill unmedicated patients with schizophrenia, 20 patients suffering from major depressive disorder, and 20 healthy controls were assessed using a PI paradigm. No significant differences in PI emerged between the groups. The results do not support this specific feature of the neuropsychological model of acute schizophrenia proposed by Gray et al. (1991).