Disparities in Screening and Treatment Patterns for Depression and Anxiety During Pregnancy: An Integrative Review.

INTRODUCTION: Symptoms of untreated depression and anxiety during pregnancy are associated with serious adverse effects for the pregnant person, birth outcomes, and child development. However, pregnant persons are less likely to be screened and treated compared with nonpregnant people. In this systematic review, we aimed to explore individual, provider, and systems factors that impact screening, identification, and treatment patterns for depression and anxiety during pregnancy. METHODS: Studies were eligible for inclusion if they were conducted within the United States and published in English between January 2012 and January 2023. Each study included analysis that compared rates of screening, identification, or treatment engagement and explicitly discussed disparities or health equity in marginalized groups. Fifteen articles met full inclusion criteria. RESULTS: Results demonstrated variation in the screening, identification, and treatment of depression and anxiety during pregnancy among diverse groups of patients. Screening rates ranged from 51.3% in Puerto Rico to 90.7% in Alaska. Among specific clinical populations, rates were as low as 2.0%. Fewer than half of patients were referred to treatment when indicated by screening or diagnoses. Patient characteristics such as age, race, ethnicity, socioeconomic and health factors, mental health history, and obesity were associated with variation in the rates of screening, diagnoses, or treatment engagement. Language factors were the most common factor associated with lower rates of screening and treatment access. DISCUSSION: Results suggest that many pregnant people are being overlooked and lack appropriate referrals or resources to access treatment. Results are consistent with previous findings that role confusion and lack of time, provider training, and interest contribute to low rates of screening and treatment. Future research must focus on system level factors to address perceived barriers to screening and treating depression and anxiety during pregnancy in a systematic and equitable way.

Impact of preference for yoga or cognitive behavioral therapy in patients with generalized anxiety disorder on treatment outcomes and engagement.

There is some, but inconsistent, evidence to suggest that matching patient treatment preference enhances treatment engagement and outcome. The current study examined differential preferences and factors associated with treatment preference for 12-week group cognitive behavioral therapy (CBT), yoga, or stress education in 226 adults with generalized anxiety disorder (GAD; 70% female, Mean age = 33 ± 13.5). In a subsample of 165 patients who reported an intervention preference and were randomized to yoga or CBT, we further examined whether match to preferred intervention improved the primary treatment outcome (responder status on Clinical Global Impressions Scale) and engagement (dropout, homework compliance). Preferences for CBT (44%) and yoga (40%) were similar among patients. Women tended to prefer yoga (OR = 2.75, p = .01) and CBT preference was associated with higher baseline perceived stress (OR = 0.92, p = .04) and self-consciousness meta-cognitions (OR = 0.90, p = .02). Among those not matched to their preference, treatment response was higher for those receiving CBT than yoga (OR = 11.73, p = .013); there were no group differences for those matched to their treatment preference. In yoga, those who received their preference were more likely to drop than those who did not (OR = 3.02, 95% CI = [1.20, 7.58], p = .037). This was not the case for CBT (OR = 0.37, 95% CI = [0.13, 1.03], p = .076). Preference match did not predict homework compliance. Overall, results suggest that treatment preference may be important to consider to optimize outcome and engagement; however, it may vary by treatment modality. Future research incorporating preference, especially with yoga for anxiety, is aligned with personalized medicine. TRIAL REGISTRATION: clinicaltrials.gov: NCT01912287; https://clinicaltrials.gov/ct2/show/NCT01912287.

Antidepressant use During Pregnancy: Knowledge, Attitudes, and Decision-Making of Patients and Providers.

INTRODUCTION: Despite the risks associated with untreated perinatal depression and anxiety, both patients and clinicians are less likely to follow evidence-based guidelines including the use of antidepressants during pregnancy. The aim of this integrative review was to describe the perspectives of both patients and prescribing health care providers regarding the use of antidepressants during pregnancy. METHODS: We performed a literature search in PubMed, CINAHL, ProQuest Central, and PsychINFO. Inclusion criteria were English language, original peer-reviewed research published within the previous 10 years that described perspectives regarding the use of antidepressants of pregnant patients or prescribing providers during pregnancy. Studies were excluded if their focus was on screening practices, treatment guidelines, or evaluation of decision support tool; medication or treatment broadly; bipolar disorder or serious mental illness; or they did not provide patient or provider perspective. This review was limited to professionals with scopes of practice that include prescriptive authority (eg, physicians, advanced practices nurses, midwives). Included articles were critically appraised and read in an iterative process to extract methodological details and synthesize findings. RESULTS: Nineteen studies met criteria for inclusion and varied by design, sample, and quality. Together, the reviewed articles suggest that patients and prescribing providers hold a range of beliefs regarding the safety of antidepressant during pregnancy. Patients and providers appear to value different sources of information and varied in awareness of the negative impacts of untreated depression and anxiety during pregnancy. Many patients report dissatisfaction with available information and distress throughout the decision-making experience. Notably, patients and providers had incongruent perceptions of the others' experience. DISCUSSION: Inconsistencies between knowledge, attitudes, and decision-making highlight the need for improved dissemination of evidence-based treatments and support increased training for psychopharmacology during pregnancy. Efforts to reduce patient distress regarding their decisions, such as adequate time and information, are indicated.