Integrated care involves systematic and coordinated medical and behavioral health care to provide the best outcomes and most effective treatments for people with multiple conditions. It improves accuracy of diagnosis, timeliness of mental health treatment, and reduces the comorbidity that psychiatric conditions contribute to medical illness.1 Integrated care in obstetrics and gynecology (Ob-Gyn) is paramount. Approximately one-third of all medical visits for women age 18 to 45 years are with an Ob-Gyn physician.2 The American College of Obstetricians and Gynecologists guidelines have steadily expanded for providers to identify, assess, and treat psychosocial concerns, including depression, intimate partner violence, smoking, and substance use.3 Ob-Gyn physicians find that a significant proportion of their patient population has psychological needs. Of the estimated 120 patients that an Ob-Gyn physician will see weekly, it is suggested that 17% will have clinical depression and upwards of 50% will have significant emotional disturbance.4
The need for integrated care is especially evident given the unique developmental periods in which Ob-Gyn physicians tend to interact with their patients. Providers treat women during key transitional phases that pose unique opportunities for psychological interventions.5 These include initiation of contraception, unintended pregnancies, childbirth, menopause, infertility, chronic illness, and interpersonal stressors. These phases allow for behavioral health needs related to sexual health, pelvic pain, psychiatric disorders, interpersonal violence, and substance use disorder to be addressed.
The perinatal period is not protective against psychiatric illness. Research has demonstrated higher rates of depression in women, as compared to men, with onset during peak childbearing years.6 One study of a perinatal cohort found that up to 50% of patients had unmet psychological needs.7 Perinatal mood and anxiety symptoms are known risk factors for adverse pregnancy, childbirth, and infant outcomes.8 Psychological symptoms can affect use of prenatal care, contribute to negative health habits related to sleep and nutrition, and increase the likelihood of substance use disorder. However, when behavioral health services were embedded within a clinic, patients were 4 times more likely to engage in treatment.7
Studies on integrated care models within Ob-Gyn have demonstrated improvements in depressive symptoms, improved adherence to treatment interventions, and overall higher treatment satisfaction.9 Additionally, patients report improved ease of care with embedded services and experience the benefit of collaboration between their providers.10 Universal screening allows patient concerns to be identified proactively.10
This article explores the development of an integrated perinatal mental health clinic. Barriers encountered and lessons learned will also be discussed considering a wide range of psychosocial factors and psychiatric diagnoses.
Perinatal Mental Health Clinic
A multidisciplinary team, comprised of a psychiatrist, psychologist, psychiatry residents, and a social worker, was developed within the Department of Obstetrics & Gynecology at a university-affiliated hospital. The Perinatal Mental Health team meets with patients who are attempting conception, currently pregnant, or within 6-months postpartum. Services are provided in the outpatient and inpatient medical settings. Perinatal psychiatrists conduct prepregnancy consultations and psychotropic medication management during pregnancy and lactation. Consultations provide in-depth discussions with patients regarding the risk versus benefit of initiating medications versus untreated psychiatric illness. Perinatal psychology specializes in assessment and treatment of psychological disorders with subspecialization in health psychology. Treatment is grounded in behavioral medicine as well as mental health. Empirically validated behavioral interventions are used to address psychological disorders, promote mood and coping, improve adherence, and modify health behaviors. Clinical social work services are also available to provide education, community resources, and emotional support to women and families, including facilitating higher levels of psychiatric care when needed.
The Perinatal Mental Health Clinic began in 2010 as a co-located psychiatry clinic offering psychiatric services for the perinatal population, in addition to the Ob-Gyn social work services previously established. The clinic expanded its multidisciplinary services a few years later with the addition of a perinatal psychologist. With the addition of the perinatal psychologist, data for 6 months indicated that the number of patients seen increased by 75%, new patient visits doubled, and established visits tripled.11
In general, no-show rates are a concern across all medical specialties and especially in mental health.12 This challenge was present when developing the clinic. Data for new patient perinatal psychiatry visits in 2014 showed a 30.56% no-show rate.13 In 2015, the clinic implemented an appointment reminder letter, and patients were informed that their initial new patient appointment would not be rescheduled if they neglected to appear. This intervention was beneficial in reducing the no-show rate for new psychiatry visits to 18.18% in 2015.13 Additionally, the inclusion of psychology services within the clinic afforded perinatal psychiatry to see a 28% increase in volume of patients and overall the no-show rate for established patients decreased by more than one-half from 22% to 10%.11 This demonstrates improved access and engagement in care as evidenced by a decrease in no-show rates for established patients.
A hallmark of integrated care is the quality of care provided through early identification and treatment of population health needs. As such, the Edinburg Postnatal Depression Screening (EPDS) is administered to patients at their initial prenatal visit, 26-weeks gestation, and at their 6-week postpartum visit. The EPDS is a widely used screening tool for postpartum depression,14 and has also been validated as a screening instrument for antenatal depression. It is a 10-item self-report questionnaire assessing mood symptoms. This measure is brief and easy to score. Medical staff use a cut-off score of 10 to prompt referral for treatment.
In addition to a screening measure, patients are also referred by a provider through identification of needs assessed during the medical visit. These include common symptoms of mood or anxiety disorders (tearfulness, irritability, apathy, sleep or appetite changes, hopelessness/suicidality), significant psychosocial stressors (including but not limited to unplanned pregnancy, consideration of termination, limited social support, and pregnancy complications), and previous psychiatric history, especially prior episodes of perinatal mood disorders (Figure 1).
Perinatal mental health referral algorithm.a EPDS, Edinburg Postnatal Depression Screening.
Patients are referred to either a perinatal psychiatrist or psychologist based on treatment need. Ob-Gyn physicians consider whether the patient has a preexisting psychiatric diagnosis (bipolar disorder, severe depression, or anxiety) that necessitates medication, whether psychotropic medications are currently prescribed, and whether the patient expresses interest in medication. Patients are also referred to perinatal psychiatry for preconception medication consultation. Alternatively, patients are referred to perinatal psychology if they are not interested in or are unsure about initiating psychiatric medications, specifically request therapy, or if the referring provider is uncertain about which treatment approach is best. Patients are also referred to perinatal psychology for coping with a broad range of medical or psychosocial stressors (high-risk pregnancies, pregnancy complications or loss, marital or family conflict, or health behavior modification).
A survey of Ob-Gyn physician attitudes and practices regarding screening for psychosocial concerns (validated measures, interview questions, or open dialogue) suggests that the majority agree with the practice and the importance of assessing psychosocial needs.15 Nevertheless, barriers at multiple levels exist that affect the movement toward integrated care. Services may not be used even when they are embedded within the clinic, often referred to as a competing and multiple demands model.16 This model posits that physicians do not have sufficient time to meet all demands from competing arenas of their own professional needs, system/organizational needs, and patient needs. Although integrated care reduces some barriers to care, it does not eliminate all of them.
As front-line providers, physicians' knowledge of and ability to identify psychiatric symptoms is critical to referring patients to mental health treatment. Ob-Gyn physicians indicate better ability to identify the presence of depressive symptoms as opposed to anxious symptoms. However, physicians are also noted to be more inclined to diagnose and treat depression with medication when patients do not meet full diagnostic criteria.17 This is a concern as one does not want to expose a woman or fetus to medication if there is no indication or, conversely, expose to medication with suboptimal therapeutic benefit. Therefore, it is vital that physicians can accurately diagnose as well as consult with specialized behavioral health providers regarding treatment. Part of the goal of the Perinatal Mental Health Clinic was to increase the capacity and confidence of the Ob-Gyn physician in assessment and management of perinatal psychiatric disorders. Clinically, an increased number of providers do report comfort with first-line management of perinatal psychiatric disorders with medications, although a fair percentage would prefer to refer to specialists. This is similar to estimates in the literature citing that more than one-half of physicians prefer to refer or directly consult with a behavioral health provider17 versus relying on their own assessment and treatment.
It is also important that physicians understand the value of behavioral health services. Research assessing primary care physician attitudes regarding behavioral health suggests that there are gaps in understanding of the specialized skill sets of behavioral health professionals and the extensive education and training.18 Similar themes were observed in the development of this integrated clinic. Ob-Gyn physicians demonstrated gaps in understanding the differences between psychiatry and psychology with respect to prescribing medications or providing psychological interventions, as well as limited understanding of the educational training in clinical psychology. When queried on perception of psychotherapy, responses included “coaching,” “talking,” or alternatively “just listening.”
Aside from the tangible knowledge of psychiatric disorders, some physicians may not be comfortable or confident in addressing psychosocial concerns during the medical visit. Ob-Gyn physicians do not feel they have received adequate training to address mental health concerns, such as depression or anxiety.17 Some are also hesitant to identify mood symptoms for fear that the patient will become dependent on them for treatment.15,17 This may lead to missed opportunities to intervene and provide necessary treatment. Historically, limited mental health services was a deterrent to identifying psychiatric health needs. An integrated model affords streamlined referrals and greater access to care. Yet, there remains a subset of providers within the clinic not using services on a consistent basis. Further research is warranted as to how an integrated model can more positively affect and support physician assessment and referral to psychiatric treatments.
Perhaps of greatest significance is whether physicians understand psychological frameworks and the potential effect that untreated mental health conditions can have on medical treatment. This is important in perinatal medicine given the link between maternal and fetal outcomes. Untreated disorders negatively affect adherence, increase health care utilization, and increase morbidity and mortality. Many primary care physicians believe in the efficacy of mental health services. However, less believe that it will lead to improved medical treatment outcomes or benefit physical symptoms, such as pain, fatigue, or overall disease process.18 Ob-Gyn physicians would benefit from knowledge regarding efficacy of psychological interventions, such as cognitive-behavioral therapy, as a means of treatment for both physical and psychological sequelae.17
Health Care System
Given the focus on clinical practice models, the health care system and organizational factors are beyond the scope of this article. However, one notable system-level barrier is the constraints of time. Physicians are expected to do more for patients in less time, which leads to insufficient time to address both medical and mental health needs. Some Ob-Gyn physicians view assessing psychological symptoms as a major time constraint and worry that it takes time away from a patient.15,17,19 Implementing a simple-to-use screening measure that does not take physician time during the medical visit is one mechanism to assess mental health needs within the limitations.
Some patient-driven barriers to effective mental health care may include socioeconomic factors, stigma, and knowledge of psychiatric care options. In studies of barriers to mental health care for women receiving treatment in Ob-Gyn settings, women cited transportation, finances, work schedule, or childcare concerns.19,20 Additionally, women report hesitancy to disclose emotional symptoms for fear of the effect it may have on parental rights as well as the overall stigma associated with mental health.20,21 Patients also identify the importance and quality of patient-provider interactions. This includes provider sensitivity, interest, and the normalization of mental health symptoms. The ability to be honest with providers has been shown to decrease many of the other common barriers cited.19,21
Further noted in the development of the clinic has been patient understanding and knowledge of mental health conditions, treatment interventions, and expectations. Specifically, patients benefit from detailed information regarding their mood symptoms, how physical and emotional symptoms interrelate, and expectations regarding treatment (time to titrate psychiatric medication, frequency of psychology visits, and active implementation of skills). Patients were observed to anticipate symptom improvement after minimal psychotherapy engagement or short-term use of medications. Ongoing education regarding medication use in pregnancy and lactation is also essential as research indicates many women discontinue psychotropic medications upon learning of pregnancy.22 Thus, potential relapse and worsening of preexisting psychiatric conditions may occur. Patient education regarding risk versus benefit of continuing psychotropic medications is important for informed decision-making.
In developing an integrated perinatal mental health team, goals should be to reduce as many barriers as feasible and to promote effective treatment outcomes. Several key strategies to achieve this include educating all medical staff, implementing screening measures, providing ongoing patient education, and continual active collaboration with the medical team.
Educate Medical Staff
All medical staff (physicians, residents, and nurses) will benefit from sound training in psychiatric diagnostic criteria, prevalence of disorders, and the potential consequences of the disorder. Education should especially focus on the effect on medical care and treatment outcomes. Information on the different mental health specialists available, including level of education and training background, and the appropriate referral mechanism, should also be considered. This will improve the medical staff's ability to detect clinically relevant concerns, reduce misconceptions and stigma, and encourage partnership with behavioral health specialists.
The educational roll out for the Perinatal Mental Health Clinic included written education to all medical staff regarding services, in addition to a treatment algorithm for referrals. Verbal, in-person education has been offered through departmental Grand Rounds as well as with ongoing didactic education for faculty and residents on perinatal mental health topics. Didactics on integrated care for Maternal-Fetal Medicine specialists was also offered in addition to attendance at inpatient nursing staff meetings for introductions and education on inpatient and outpatient services. Our experiences suggest even further in-person, comprehensive education is critical given ongoing barriers with respect to knowledge and understanding of mental health services. Including all medical staff, especially care coordinators and nurses, in educational efforts is paramount given their close contact and relationship with patients. Additional areas of promotion include education via written handouts or treatment reminders in clinic examination rooms. These can serve as reminder prompts to assess and refer. This visual cue is likely to also aid the patient in being more comfortable discussing mental health needs, either independently or when asked directly. Consider email updates for treatment successes or programmatic changes or more formalized annual department updates on program development, referrals, and patient care topics. Ensure ongoing education through consistent in-person collaboration with providers on direct patient cases whenever possible.
Implement Screening Measure
Screening measures allow for the improved detection of clinically relevant psychosocial concerns and early treatment intervention. Choose a screening measure that medical staff will find easy to implement whether it be structured questions or patient self-report measure, which easily integrates into the medical record. Develop a clear process for referrals with a consistent feedback loop, ideally a system that allows documentation of screening measure, the referral to perinatal mental health, and the outcome of that referral, such as specific patient information or treatment recommendations. In the Perinatal Mental Health clinic, the EPDS was used on a consistent basis when initially implemented; however, over time and as additional responsibilities arose, the consistency of use decreased to where it was not administered prenatally. The most frequent use of the tool has been at the 6-week postpartum visit; however, this may delay needed treatment until after symptoms have already emerged. Regularly monitor use of the screening measure and elicit feedback from medical providers regarding the process to ensure it remains feasible and effective.
Encourage medical professionals to provide patients with ongoing reassurance and normalization of perinatal mental health concerns, knowledge that help is available, and treatment options. Behavioral health professionals can support patients by providing psychoeducation on their specific diagnosis, how physical and emotional health interrelate, and treatment expectations. With the development of the Perinatal Mental Health Clinic, all patients are provided with a patient education packet at time of discharge after admission to Labor and Delivery. Additional patient education opportunities include prenatal education classes to educate expectant parents on psychological health throughout pregnancy and postpartum. Written information can be included in prenatal information packets that address perinatal mental health, self-care, treatment options, and scheduling information.
Ob-Gyn physicians, medical professionals, and patients will all benefit from active, ongoing collaboration regarding patient care. Psychiatrists and psychologists can help treating providers understand a patient's emotional and behavioral symptoms and the effect on medical care and the patient-provider interactions. Likewise, behavioral health providers benefit from having a sound understanding of the medical needs and treatment plan for patients. Active collaboration can be achieved through curbside consultations as well as documentation within medical records and forwarded to medical providers. Ideal models would implement shared appointments with obstetrics, psychiatry, psychology, and social work. Miller et al.23 implemented a Perinatal Depression Management program focusing on treatment entry through collaborative provider and patient engagement strategies within the same clinic visit. This model demonstrated improvements in identifying clinical diagnostic criteria and significantly improved treatment entry for women meeting criteria for clinical depression.
Integrated care allows greater ease of access and collaboration between Ob-Gyn professionals and behavioral health specialists, but barriers remain. Future research should look at more detailed exploration of barriers specific to integrated models in Ob-Gyn and practice guidelines to reduce barriers. Structured training and educational programs as well as guidelines for implementation should be identified.
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