Advances in virtual care for perinatal mental disorders
Authors: Simone N. Vigod, Cindy‐Lee Dennis
Journal: World Psychiatry (2020)

In their excellent review, Howard and Khalifeh1 ably outline the extent and burden of perinatal mental disorders internationally on women, children and families, and highlight the evidence-based treatments that can address these disorders. A key point in the review is the ever-consistent evidence that the vast majority of these disorders remain untreated or undertreat-ed, in high, middle and low income countries alike. It is estimated globally that as few as one in every five women affected by a perinatal mental disorder receives the required treatment to achieve remission2. With 130 million births per year worldwide, and an estimated 20% of women affected annually, this means that about 2 million women each year will experience untreated or undertreated perinatal mental illness, with its substantial impact across generations. The reasons why perinatal mental disorders are undertreated are multiple, complex and often inter-related. Some women are not offered, or do not seek, treatment due to lack of awareness about their condition, or due to shame, stigma, or family and community-related beliefs and pressures about mental illness around the time of pregnancy3. Evidence-based psychotherapies are a highly effective treatment option for common conditions such as depression, anxiety, obsessive-compulsive disorder, and trauma and stressor-related disorders, and preferred by most women. Yet, pregnant women may be unable to take time off work for regular in-person sessions while putting in hours prior to a parental leave. Postpartum, some women may not be able to travel initially after caesarean sections, and unpredictable infant schedules may make it difficult – if not impossible – to attend regular in-person appointments. In more severe illnesses, women and providers are often reluctant to initiate medications and/or increase dosages to adequate levels, especially when specialist support is unavailable to help determine whether potential benefits outweigh evidence around safety concerns4. Limitations in access to and uptake of treatment are compounded by a lack of specialized psychological and psychiatric support in many jurisdictions, especially outside of high income urban settings, and by the cost of services, transportation to reach them, and childcare during treatment sessions. Virtual care – defined as any interaction occurring remotely between patients or members of their circle of care that uses communication or information technology to facilitate or maximize quality and effectiveness of patient care5 – is a very attractive solution to these important and long-standing barriers to treatment of perinatal mental disorders. Virtual care interventions may range from self-guided patient-facing applications, to asynchronous patient-provider or provider-provider communications, to live interactions over telephone or video that allow for care at a distance, or combinations of these. Models of care that leverage mobile applications are particularly accessible, sustainable, and provide low-cost scalable opportunities. Mobile technology has spread rapidly around the globe. Today, it is estimated that more than five billion people have mobile devices, and over half of these connections are smartphones, making virtual care a viable option for many. As such, virtual care has great potential to address some of the urgent challenges in ensuring timely and equitable access to effective health services for women with perinatal mental disorders across the globe. Before we uptake these novel interventions, important questions need to be addressed. What types of virtual care interventions have been introduced in the treatment of perinatal mental disorders, and for what vulnerable sub-populations? Are these interventions reaching women who otherwise would not receive treatment? Are they as effective as in-person care? Do they need to be as effective as in-person care, if it means that some people who would otherwise receive no care at all are now receiving at least some evidence-based treatment? Multiple interventions are being developed and evaluated, with many showing substantial promise for addressing the unique treatment barriers for perinatal mental disorders. A meta-synthesis of five qualitative studies reported that online peer-moderated discussion groups might reduce stigma and increase help-seeking. The beneficial effect may be related to helping women reconceptualize what it means to be a "good mother" and separate the stigma of experiencing mental illness from that of their maternal identity. A recent meta-analytic review (including five randomized controlled trials) found that therapist-assisted web-based psychological interventions may also be an effective option for the treatment of perinatal depressive and anxiety symptoms, with medium-sized effects6. This is a highly attractive model clinically, as this type of intervention is more efficient than 1:1 live interactions, in that one clinician may be able to support more women in a specified time period, and women can work on their exercises during their own time, thus reducing the challenge of finding specific times for therapy on a continual basis. In terms of "live" virtual care interventions, a recent trial of nurse-delivered telephone interpersonal therapy (IPT) for postpartum depression conducted by one of us (N=241) found that women receiving IPT were 4.5 less likely to be clinically depressed at 12 weeks post-randomization compared to those who received stan-dard available care7. Some smaller "pilot" studies have started to make comparisons of video-based to in-person care, showing that, while women like in-person care when available, video- and telephone-based treatments provide more conven-ience, related to needing time off work and unpredictable child schedules8. Virtual care is also being leveraged to support women and health care providers when access to specialized advice is not immediately available in their jurisdictions. In the US, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms allows rapid telephonic access to perinatal psychiatric consultation for obstetrical providers, so that women can be treated in their antenatal and postnatal care settings. In the first 3.5 years, MCPAP for Moms enrolled 145 obstetric practices, conduct-ed 145 trainings for 1,174 health care providers, and served 3,699 women, suggesting excellent utilization, with growing evidence of effectiveness9. In Canada, we found that decisional conflict around whether or not to use antidepressants in pregnancy was significantly reduced for preconception and postpartum women after using an on-line interactive patient decision aid, specifically among those who had no ready access to specialized reproductive psychiatric care10. One notable learning in the virtual care research is that not all interventions are one and the same. Even subtle differences in intervention design, application and dosage can impact acceptability, adherence and efficacy. For example, there is evidence to suggest that therapist-facilitated web-based psychological treatment is associated with high attrition when low-intensity online coaching is provided, but retention rates improve significantly when modified to telephone-based coaching6. Future research should target virtual care initiatives that improve access and reach among socio-economically vulnerable populations, including those with lim-ited access to web or telephone, or those who have difficulty finding a private safe space to engage (e.g., in the setting of intimate partner violence). Further, effectiveness across cultures is important to determine whether standard interventions re-quire modification. Given the flexibility of digital technology in modern health systems, virtual care is a promising and exciting area to examine in order to address the undertreatment of women with perinatal mental disorders and improve access, uptake and reach. Rigorously designed trials and protocols to address unanswered questions are critical to ensuring that we make the most of this unprecedented opportunity.