Background

The perinatal period from pregnancy through to the first year after birth, is recognised as a time of significant risk for development, relapse or recurrence of mental health problems [1, 2]. The term perinatal mental health problems (PMHPs) encompasses the full range of mental health disorders encountered by women in this period ranging from perinatal depression and anxiety to more serious perinatal mental health (PMH) issues including severe depression, bipolar disorder, psychosis, and posttraumatic stress disorder [1,2,3].

It is important to recognise and treat PMHPs across the diagnostic spectrum [4,5,6] as PMHPs may have significant consequences for the woman, her baby and family. Antenatal depression is associated with preterm birth and low birthweight [7]. Perinatal depression and anxiety are associated with negative outcomes for the developing fetus, child, adolescent [4, 6, 8,9,10,11] and partner relationship [9]. In the primary care setting, family physicians (FP’s) are particularly well-placed to assume a leading role in the management of PMHPs based on their role as the primary care provider [12, 13]. In this context, FP’s have; knowledge of a woman’s general wellbeing and mental health history, ongoing contact with mothers, infants and families throughout the perinatal period and liaise with primary and specialist mental health services [12, 13]. Current policy and practice guidance largely overlook the role of FPs in supporting women with mental health issues during the perinatal period [13]. Furthermore, the need to synthesise healthcare professionals (HCPs) experiences of providing care to women with PMHPs and to triangulate findings with the synthesis of women’s experiences has been identified [14]. A systematic review [15] examined quantitative studies on FPs recognition and management of perinatal depression and anxiety. Similarly, a meta-synthesis explored the diagnosis and management of perinatal depression and anxiety in general practice [16]. This current review synthesises the findings from qualitative and quantitative studies to provide a comprehensive review of the global evidence exploring FPs role in PMH. To this end, an integrative review of qualitative, quantitative and mixed-method studies on FP’s experiences of caring for women who experience PMHPs was conducted. Within this review, the term FP is used and incorporates the term general practitioner (GP) which is the term used in the Republic of Ireland, United Kingdom, Australia and Commonwealth countries.

Methods

This review was guided by Whittemore and Knafl’s [17] integrative review methodology framework, which combines findings from qualitative and quantitative research on a specific subject to provide an all-encompassing understanding of the review question. The review was informed by the modified MOOSE standards [18] for reporting systematic reviews of observational research and reported across Whittemore and Knafl’s [17] five stage framework; problem identification, literature search, data evaluation, data analysis and presentation of findings.

Problem identification

The aim of this integrative review was to explore the evidence relating to FP’s perceptions and experiences of caring for women who experience PMHPs to develop practical learning points that can be applied to healthcare professional training programmes and inform practice, research, education and policy developments.

Objectives

The objectives of the review were to systematically identify, select, critically appraise and synthesise studies that examine FPs’ perceptions and experiences of caring for women who experience PMHPs.

Literature search

Medical subject headings (MeSH), specific database headings, thesaurus and key words were used in conjunction with Boolean operators, truncation and synonyms (Table 1) to search seven electronic databases from January 2000 to March 2016. Databases searched included: Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane, SCOPUS, Web of Science. The search was piloted in MEDLINE and CINAHL and individually adapted to each database.

Table 1 Search Terms
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Qualitative, quantitative and mixed-method studies published in peer-reviewed journals that researched FP’s experience of caring for women with PMHPs were eligible for inclusion. A 15 year timescale was chosen to ensure a comprehensive coverage of contemporaneous relevant literature given the increasing emphasis on PMH during this timeframe.

Results of database searches identified 1125 articles, which were exported to EndNote reference management system. Duplicates were removed (Endnote and manually) resulting in 971 articles. Titles and abstracts were screened by MN for relevance based on inclusion criteria and discussion with the research team and 25 were forwarded for full text evaluation (MN and OD).

Data extraction and evaluation of data

Evaluation of the 25 full text articles comprised of two levels of assessment. The first level assessment involved removal of articles based on inclusion and exclusion criteria. Twelve studies met the inclusion criteria. The reference lists of included studies were examined and one additional study was identified [19] resulting in 13 studies for review, comprising 5 qualitative studies and 8 quantitative studies (Fig. 1). Data were extracted on study aim, design, sample strategy and size, data collection method, analytical approach, strengths and limitations and key findings (Table 2).

Fig. 1
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Prisma Flow Diagram

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Table 2 Descriptive characteristics of studies included in the review
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The second level of assessment involved a critical appraisal (MN, RG and OD) to determine methodological quality of included studies. Due to the variety of methodologies and designs, two method-specific tools were identified to assess quality of evidence. For qualitative studies, the Critical Appraisal Skills Programme (CASP) [20] tool was used (Table 3) and the Rees et al. [21] survey checklist (Table 4) was utilised for cross-sectional studies. Each criterion was recorded as “Yes” or “No” or “Clear” or “Unclear” and results of appraisal were discussed between MN, OD and RG with discrepancies resolved by consensus. Overall studies were found to be of good methodological quality with qualitative studies meeting between seven and nine of the ten appraisal criteria (Table 3) and quantitative studies meeting between eight and thirteen of the fourteen appraisal criteria (Table 4). All studies identified research aims, justified the appropriateness of design, used well-defined sampling strategies, presented clear statements of findings and outlined the value of their research. In terms of the quantitative studies, response rates varied between 19% [22] and 79.2% [23] and only two studies attempted to explore non-responders. Studies were limited to a convenience sample in a specific geographic area (n = 4, Table 4). Eight studies did not provide sufficient information to appraise validity and reliability of measures (Table 4). Four qualitative studies were unclear regarding data saturation (Table 3) and three did not report an explicit statement of ethical approval or informed consent (Table 3). Four qualitative studies did not provide details of adequate consideration of the relationship between researcher and participants (Table 3).

Table 3 Methodological quality of qualitative studies
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Table 4 Methodological quality of quantitative studies
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Analysis of data

Given the heterogeneity of included literature, thematic analysis of extracted findings of each study was undertaken [24] because of its potential to draw conclusions based on common elements [25]. The steps used to conduct thematic analysis were guided by Lucas et al. [25] and Smith et al. [26].

Presentation of results/findings

Table 2 displays the characteristics of the included studies. Studies were conducted in the USA [19, 27], Netherlands [21], Canada [23], Australia [23, 28, 29], UK [30,31,32,33], Scotland [34], Israel [35] and Brazil [36]. All eight quantitative studies were cross-sectional in nature. Sample sizes varied across these studies and ranged between 32 to 362 respondents. Qualitative studies consisted of one qualitative descriptive [36] and four broad qualitative studies [30,31,32,33]. Qualitative study sample sizes ranged between 5 [32] and 19 [30,31,32] participants. Four articles reported on results from two studies [28, 29] and [30, 31] however, authors reported different aspects of findings in each of these articles. Five studies focused on PPD [27, 30, 31, 35, 36], three examined FP’s recognition and management of perinatal depression [19, 28, 29] one study explored PMH [32] and four studies focused on the use of antidepressants [22, 23, 33, 34].

Results

The findings of the review are presented under three main themes generated through analysis: identification of PMHPs, management of PMHPs in primary care and barriers to care provision. These broad themes contain a number of sub-themes as illustrated in Fig. 2 and Table 5 contains excerpts from the original studies to support these findings.

Fig. 2
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Themes and sub-themes

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Table 5 Excerpts from original studies
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Identification of PMHPs

Identification of PMHPs

The theme identification of PMHPs explores timing of screening, approaches to screening and factors that influence screening practices.

Timing of screening

The timing of screening was identified in three studies. In one study [27], 71% of FP’s screened often or always at routine postpartum gynaecologic visits and 46% at well child visits. Furthermore, 70.1% of the respondents in a second study [19] reported that they screened women for PMHPs monthly/weekly/daily. However, 29.9% reported never/rarely assessing for maternal depression. On the contrary, in the third study FPs reported not routinely screening for PPD [32] (Table 6).

Table 6 Screening tools identified within studies
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Approaches to screening

There was no consistent approach to screening for PMHPs. Screening focused on PPD with limited evidence of screening for anxiety or any other PMHP. A range of screening tools were used by FPs to screen for PPD (Table 6). A reluctance of FP’s to use screening instruments or actively enquire about symptoms of PPD was identified with FP’s relying on instinct or clinical intuition to alert them to the possibility of PPD [30, 31]. Similarly, FP’s appeared highly resistant to using validated screening tools and instead “privileged intuition over instrumentation” [32]. However, 83% of FP’s [35] reported that they would be willing to use a brief questionnaire to identify women with signs of PPD. Similarly, over 90% of FP’s [19] reported a willingness to implement a validated two-item screening tool.

Factors that influenced screening

Factors associated with more frequent screening included the FP being female, knowledge of the prevalence and morbidity associated with PPD, training in PPD during residency and through evidence from medical literature review [27]. Some FP’s reported consciously inhibiting disclosure if they did not have access to referral pathways and they felt that women would recover without formal interventions [30, 31]. The importance of establishing trusting relationships with women to support screening and diagnosis of perinatal depression was identified [32].

Management of PMHPs in primary care

This theme explores strategies that FP’s instigate to care for women who experience PMHPs under the two subthemes of pharmacological management and available supports.

Pharmacological management

Across studies, pharmacological management of PMHPs was identified as the main treatment modality offered to women in primary care. In response to the vignette [28], FP’s preferences were for antidepressant medication (antenatally 77% and postnatally 97%) which contrasted strongly to women’s preferences for antidepressant medication (antenatally 22% and postnatally 54%). FP’s were also significantly more likely to choose antidepressant medication than Maternal Child Health Nurses (MCHNs) and midwives (95% CI 8.4–23.2 and 20.9–34.3 respectively) [29]. However, when FP’s were asked about their beliefs around the usefulness of interventions for perinatal depression, they identified antidepressant medication as a third choice behind counselling and partner support for women [28]. Similarly, 92% of FP’s [19] typically treat maternal depression by prescribing medication followed by referral (82.29%) to the mental health specialist off-site and 70.1% provide counselling in office. However, in another study one in ten FPs surveyed [34] preferred not to prescribe antidepressants and one in four FPs would avoid ‘all drugs’. Reasons for avoiding antidepressants were lack of practitioner experience (n = 7), high teratogenicity risk (n = 5) and lack of data (n = 4). The contrasting findings may be related to the use of different questionnaires in the studies that examined FPs perceptions on perinatal antidepressant treatment. FPs were reluctant to identify PPD when the only course of action they felt available to them was prescribing antidepressants [31]. Similarly, FPs [33] viewed medication as a necessity rather than a choice because of the limited availability of referral options. The main reason for treating depression or anxiety during pregnancy was that the seriousness of maternal complaints outweighed possible risks for the child [22]. Treatment decisions involved balancing the impact of the severity of symptoms with the possibility of adverse effects of antidepressants on the foetus and timing of treatment [22, 33].

Factors that influenced prescribing practices included the information available about the safety of antidepressant medication in pregnancy, belief that pregnant depressed women should be treated differently from non-pregnant depressed women, concerns over the legal liability and patient concerns [23]. Female FP’s also acknowledged that their personal experience of pregnancy influenced treatment decisions [33]. FP’s reported using different sources of information on antidepressant use in pregnancy including consultation with pharmacists, formulary issues, relevant manufacturers, the internet and specialist advice [22, 34]. FP’s reported that they felt hesitant to prescribe and tapered dosages of antidepressants rather than discontinuing medication [23]. FP’s relied on their own professional experience and knowledge of individual women to make complex risk-benefit treatment decisions [33]. Professional experience was used to determine the level of involvement that women wanted in the decision-making process [33].

Available supports

Across the studies FPs reported making referrals to mother–baby units, counsellors, psychiatrists, mental health specialist, local mental health teams, midwives, health visitors, community support groups, voluntary organisations, telephone/crisis line and naturopath [19, 28, 30, 31, 33].

Barriers to service provision

Barriers to provision of effective PMH care were identified across studies and are reported here under three subthemes: service user, physician and system level barriers.

Service user

A reluctance of women to ask for help, denial/non-acceptance of women with current symptoms of perinatal depression and perceived stigma associated with PMHPs were identified as barriers to screening and treatment by FPs [19, 28]. Furthermore, FP’s were reluctant to use the label ‘PPD’ with women because of the stigma that they perceived women felt, the effect this would have on the consultation and because they felt women would recover without formal interventions [31]. However, other FP’s in the same study described consultations where women were happy to accept the label ‘PPD’ [31]. Language barriers or family beliefs were reported by 23% of FP’s as barriers to treatment [28]. While, Edge [32] found that some staff appeared to adopt a ‘colour-blind’ approach to caring for women from diverse ethnic groups instead concentrating on language barriers. It was acknowledged that Black Caribbean women’s psychological responses were interrelated to their cultural identity and that this may affect their comfort in seeking support for mental health issues from HCPs or from social/family resources [32]. Lack of consultation with FP’s by women led to abrupt stopping of antidepressants [33]. FP’s viewed involvement of women in treatment decisions as central to women’s empowerment but this was limited by clinical complexities and the level to which women wanted to be involved in decisions about medications in pregnancy [33].

Physician

FP’s recognition of their responsibility for PMH care influences professional behaviours and the majority of FPs identified their role in the diagnosis and management of perinatal depression. FPs were more likely to feel responsible for and confident in treating maternal depression than obstetricians and paediatricians [19]. However, a lack of responsibility for follow-up care was identified as a barrier to screening and treatment for PMHPs [19]. Furthermore, Chew- Graham et al. [30] reported that changes to National policy and local organisations influenced care with no one HCP assuming overall responsibility for care of women with PPD. FPs in Brazil [36] saw PPD as the responsibility of psychiatrists in relation to identification, diagnosis and treatment.

Time was reported across the studies as a barrier to screening and treatment of PMHPs [19, 28, 36]. A significant number of respondents in Seehusen et al.’s [27] study believed that screening at every postpartum visit (19.2%) and well-child visit (34.9%) would take too much effort. Similarly, FP’s in McCauley and Casson [33] identified increasing workloads as barriers to complicated treatment decisions.

FP’s reported a wide variety of knowledge and awareness of PMHPs. FP’s had similar awareness scores for perinatal depression compared to both midwives and MCHNs and depression was more likely to be considered postnatally across all three groups [29]. Multifactorial causes of PPD were identified including attributing PPD as a social response to birth and the transition to parenthood [30, 31]. FPs expressed ambivalence about the status of PND as a unique separate condition when compared with depressive illness experienced by women at other times in their lives [30, 31]. A lack of knowledge was reported as a barrier to screening and treatment for PMHPs by some FPs [19]. FP’s in Brazil reported limited knowledge, awareness and recognition and direct clinical experience of caring for women who experience PPD [36]. They viewed PPD as an uncommon problem attributed to hormonal changes [36]. A lack of knowledge was evident around the consequences of perinatal depression with only 20% of FPs in the study by Ververs et al. [22] recognising the negative effects of depression and anxiety on a child’s development. FP’s also reported a lack of awareness of culturally specific issues [32].

Formal training on PPD was received from a variety of sources including residency training, medical literature and through continuing medical education conferences [27]. A lack of confidence, competence and training in identifying and managing PMHPs irrespective of ethnic or cultural backgrounds was reported [23, 32, 36]. More training on mental health issues in the form of continuing professional development opportunities, guidelines specific to PMH and computer deliverables was suggested to support FP’s [19].

System level barriers

FP’s reported low usage of guidelines in practice due to lack of time and the volume of available guidelines [32, 33]. FPs acknowledged that guidelines provide best practice advice, a professional reference point and can be used as a defence against litigation. However, guidelines were also identified as generic and lacking in specific and clear direction on treatment in the perinatal period. It was also reported that guidelines may be restrictive and may inhibit flexibility and knowledge resulting in women’s individual needs not being met [33]. A lack of specific or accurate guidance was described as a barrier to information provision and led to under treatment of pregnant women in general practice [33, 36].

A lack of available and timely access to resources, the absence of clearly defined care pathways and insufficient specialist PMH services were identified as a barrier to treatment for women with PMH issues [28,29,30,31,32,33, 36]. In a further study, 29% of GPs reported never referring a woman who is pregnant and on anti-depressants to a psychiatrist and 50% only referred occasionally [22]. In the study by Leiferman et al. [19], 62.8% of FPs reported never/rarely referring patients for treatment for maternal depression. A lack of cultural competence in services acted as a barrier to detection of PMHPs [32]. Inadequate continuity of care, delayed access to treatment and health services offering limited appointment availability were identified as barriers to disclosure and identification of perinatal depression [31, 33].

Discussion

The aim of this integrative review was to examine the totality of evidence relating to FP’s perceptions and experiences of identifying and caring for women who experience PMHPs. This review identifies a number of aspects to consider within the FP role and service provision in the broader context such as approaches and factors that influence screening, management of PMHPs and barriers to service provision including access to appropriate referral pathways and training opportunities. A summary of the synthesis and recommendations are provided in Table 7.

Table 7 Summary of synthesis
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A low level of identification of women who require support has been cited as a significant barrier to providing more effective PMH care to women and their families [13]. This review identified variable screening practices across studies with clinical discussion identified as the main method of identification similar to findings by Khan [13]. Variations in screening practices may be explained by lack of standardised guidelines. Several validated screening tools are available to aid timely detection of perinatal depression and anxiety [37, 38]. The findings suggest that a multimodal approach to screening is required incorporating education and training, PMH specific guidelines and resources to address FPs confidence, knowledge, attitudes and support FPs to combine clinical judgement with screening tools. Furthermore, calls have been made for enhanced screening for antepartum suicidal ideation because pregnant women are more likely than the general population to experience suicidal ideation [39]. The key to effectiveness of PMH screening programmes is a systematic process of following up all positive screening results with further clinical assessment for depression and anxiety and access to effective interventions, which in return has potential to positively impact on outcomes for women and their families [40]. In addition, health promotion campaigns that target PMH awareness for society are required to create awareness and reduce the stigma associated with PMH.

One of the barriers to identification and care of women identified by FPs was the stigma associated with PMHPs, which FPs perceived inhibited women from disclosing their symptoms. In a systematic review and meta-synthesis of qualitative studies focusing on the experience of care for PMHPs for women in the UK, Megnin-Viggars et al. [14] identified that stigma and fears about losing custody of their baby acted as a barrier to disclosure. An earlier systematic review that explored experiences of motherhood among women with severe mental illness (SMI) [41] found that stigma associated with a psychiatric diagnosis was reinforced by also being a parent and prevented women from discussing PMHPs openly and seeking help. Stigma prevents the establishment of a meaningful therapeutic relationship with HCPs, which is essential for disclosure of need [41]. Furthermore, stigma which may exist at an individual level can be reinforced at a systems level where there is a lack of resources and limited options available to support FP’s and women when PMHPs are disclosed or identified through screening. However, in other studies women described consciously inhibiting disclosure of their feelings to FPs because of personal barriers but also because of FP characteristics such as a perception that FPs were not willing to listen [31]. Women who did feel comfortable disclosing their psychological distress described the importance of having a good relationship with their FP [31].

This review has highlighted a range of contextual factors that may influence professional decision-making. Time was consistently identified as a barrier to providing optimal screening and care of women experiencing PMHPs. The longer the consultation with the woman the more likely that rapport will develop with the HCP, which in turn increases the probability that the woman will feel comfortable opening up about her PMH issues [42]. Women’s experience of FP’s as being too busy or unwilling to listen or dismissive of women’s attempts to communicate their psychological distress has been identified as a barrier to person-centred care [14]. FPs reported language as a barrier to diagnosing PMHPs and Ta Park et al. [43] identified the importance of examining the role of linguistic isolation from the general population as a barrier to seeking help for PMHPs. While, Watt et al. suggest that training must support FPs to recognise and adapt to different cultural expressions of psychological distress [44]. FPs identified the difficulty in women receiving timely initial and follow up appointments in busy practices as a system barrier to women receiving care a view corroborated by women [31]. Negative perceptions of FPs were associated with feeling rushed through consultations or being unable to make appointments due to a lack of FP availability [45].

One of the system barriers identified in this review was a lack of available PMH services and Newman et al. [46] contends that without sufficient resources it is difficult for service providers to offer a variety of effective pathways to recovery. Professional decision-making may be influenced by availability of PMH service referral options and integrated care pathways and there is evidence from this review that where FPs do not have access to these referral pathways that this influences the identification and treatment of women. Milgrom et al. [40] argue that screening without the availability of effective treatment options will be ineffective in reducing morbidity or improving outcomes for women and families. Systematic screening and specific referral pathways that incorporate a range of PMH health services including access to infant mental health interventions in the community are required to support FPs in the identification and treatment of PMHPs [47].

Consistent with the literature, findings of this review were that the primary mode of treatment offered by FPs was pharmacological treatment options. Only a minority of women require pharmacological treatment and the effectiveness of psychological therapies for treatment of perinatal depression and anxiety has been established [48]. Significantly, Megnin-Viggars et al. [14] identified the importance of the FP-service user relationship in the context of treatment decisions where women valued a discussion with the FP that addressed their fears about anti-depressants. While Slade [49] identified the importance of HCP’s interpersonal skills, their ability to form a relationship and engage women who have PMHPs as key determinants of women’s decision to accept help and successful outcomes including linking women with the appropriate interventions.

Counselling was identified as an option provided by FPs in two studies. This option is worthy of note given that both pharmacological and non-pharmacological treatment options need to be available and considered for effective treatment of PMHPs. Findings from a small randomised controlled trial (n = 68) suggest that FP management of PPD when augmented by a Cognitive Behavioural Therapy counselling package may be successful in reducing depressive symptoms in women compared to FP management alone [40].

PMH training by FPs was predominantly undertaken in residency training and ongoing education was primarily through reviewing literature rather than formal training opportunities specific to PMH. The importance of training key primary care professionals towards improving current treatment pathways for PPD has been highlighted [40]. There is evidence that training may be effective in increasing FPs effectiveness in identification of PMHPs [13]. Specific PMH training for trainee and qualified FPs is required and consideration should be given to multidisciplinary education programmes, which would enable HCPs with a remit for PMH to dialogue and gain a greater understanding of each HCPs role in PMH care.

Implications for policy, practice, research and education

Perinatal mental health issues are recognised as an important cause of morbidity and mortality for women, their babies and families and requires healthcare systems across the world to address this area to ensure a consistent approach to screening for PMHPs and equality of access to PMH services and interventions. FPs as the first access point for prevention and early identification of PMH concerns, are ideally placed to meet this agenda but require supports to optimise their role in PMH. FPs require timely access to a range of culturally sensitive PMH services to optimise their ability to support women, their babies and families who experience PMHPs. When FPs have access to PMH specialist health services including a range of psychological and infant mental health interventions this could potentially lead to effective treatment engagement and improve short and long- term outcomes for women, their babies and families. All interactions with women and their families may serve as an opportunity to identify PMHPs and FPs appear open to incorporating a brief validated screening tool into primary practice. Research that examines PMH service needs of FPs has the potential to inform policy development in this area. This review highlights the need for further research to explore the type of screening that is being undertaken by FP’s, specifically screening tools used e.g. clinical interviews, and factors that facilitate effective PMH care in primary care. Furthermore, FPs require guidance on optimising women’s involvement in treatment decisions. Research that examines training needs in relation to PMH and the preferred format of education could be used to inform FP training programmes and curriculum development around PMH (Table 7).

Strengths and limitations

We employed a robust methodology to identify, select, appraise and synthesise the evidence from a broad range of qualitative and quantitative studies. In addition, we adhered to the relevant standardised reporting guidelines to conduct and report the findings. These methods serve to capture the totality of evidence with respect to the care and management of PMHPs from the perspective of FPs. We also included studies from a broad range of countries, thus enhancing the generalisability of the findings. However, the findings need to be considered in the context of the study limitations. While the research team developed the search string a single reviewer performed the literature search in consultation with a librarian and screened title and abstracts. Only research articles from 2000 onwards have been included and additional studies that would add to the current body of literature may have been excluded from the review. The process of combining papers with different methodologies and frameworks may result in inaccuracies and bias however it is also seen as a strength of the IR methodology as it provides a comprehensive synthesis of varied perspectives from published evidence.

Conclusion

This IR has highlighted barriers and facilitators that influence FPs’ practice in PMH care and findings are relevant to the current discourse. The collective interpretation revealed that FP’s recognise their role in relation to PMH care however FPs receive variable preparation for this role, there is no consistent approach to screening, the main treatment modality identified was pharmacological management of mood disorders and FPs reported limited access to PMH services which has implications for FPs decisions around pharmacology. Family physicians require access to culturally appropriate services to improve detection and treatment of women from different cultural backgrounds. A biopsychosocial model or approach incorporating education, management and promotion of PMH is required to optimise care to women and their families in the perinatal period.