Delivering perinatal depression care in a rural obstetric setting: a mixed methods study of feasibility, acceptability and effectiveness

Abstract

Objectives: Universal screening for depression during pregnancy and postpartum is recommended, yet mental health treatment and follow-up rates among screen-positive women in rural settings are low. We studied the feasibility, acceptability and effectiveness of perinatal depression treatment integrated into a rural obstetric setting.

Methods: We conducted an open treatment study of a screening and intervention program modified from the Depression Attention for Women Now (DAWN) Collaborative Care model in a rural obstetric clinic. Depression screen-positive pregnant and postpartum women received problem-solving therapy (PST) with or without antidepressants. A care manager coordinated communication between patient, obstetrician and psychiatric consultant. We measured change in the Patient Health Questionnaire 9 (PHQ-9) score. We used surveys and focus groups to measure patient and provider satisfaction and analyzed focus groups using qualitative analysis.

Results: The intervention was well accepted by providers and patients, based on survey and focus group data. Feasibility was also evidenced by recruitment (87.1%) and retention (92.6%) rates and depression outcomes (64% with >50% improvement in PHQ 9) which were comparable to clinical trials in similar urban populations.

Conclusions for practice: DAWN Collaborative Care modified for treatment of perinatal depression in a rural obstetric setting is feasible and acceptable. Behavioral health services integrated into rural obstetric settings could improve care for perinatal depression.

Keywords:

• Perinatal depression
• Collaborative Care
• obstetric clinic
• rural

Ethical approval

All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Acknowledgements

The authors would like to thank Nancy Grote, PhD and Anna La Rocco Cockburn, LICSW, MPH, for training the care managers; Erin McCoy, MPH for conducting the focus groups, Theresa Hoeft for helping with qualitative analysis, and Terel Cuevas, RN, Celisa Hopkins, BA, and Jennifer Sumner, RN, the wonderful care managers. We also extend our gratitude to the original DAWN team – Wayne Katon, MD (posthumously), Jennifer Melville, MD, MPH, Carmen Croicu, MD and Evette Ludman, PhD. We thank Anne Turner, MD for feedback provided in her role as thesis advisor to Dr. Bhat.

Disclosure statement

The authors have no conflict of interest to disclose.

Current knowledge on this subject

• Perinatal depression is common and has implications for mothers and children. While screening for perinatal depression is becoming common practice, follow-up rates for mental health treatment remain low. Collaborative Care integrates mental health treatment in medical settings and is feasible and effective in urban primary care and obstetric settings.

What this study adds:

• It is feasible to implement Collaborative Care for perinatal depression in a rural obstetric setting. Recruitment and retention rates and depression outcomes are similar to those in other settings.

Additional information

Funding

DAWN was funded by 5R01MH085668-05, PI Unutzer.At the time of this study, Amritha Bhat was a postdoctoral fellow in the NIMH 537 T32 MH20021 Psychiatry-Primary Care Fellowship Program Training Grant. Amritha Bhat also acknowledges funding for this work from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (Title V, Social Security Act), grant # T76MC00011–21-00.