Skip to main content
NCBI home page
Springer logoLink to Springer
. 2022 Sep 26;25(6):1029–1039. doi: 10.1007/s00737-022-01251-7

Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review

Celine K Klatter 1,2,✉, Leontien M van Ravesteyn 1, Jelle Stekelenburg 1,2
PMCID: PMC9734206  PMID: 36163596

Abstract

Mental disorders during pregnancy are common, with long-lasting negative effects on mother and child. Treatment of these women is challenging, because of the high incidence of additional psychosocial problems and barriers on population and healthcare level. Collaborative care, collaboration between mental health and obstetric care professionals, may help to overcome these problems. The aim of this review is to review antenatal mental health interventions and analyse the impact of collaborative care. Two independent reviewers searched for RCT’s in PubMed, Embase and PsycINFO. Trials studying the effect of psychological or pharmacological interventions on the mental health of pregnant women with psychiatric symptoms (and psychosocial problems) were eligible for inclusion. Two reviewers independently abstracted data and assessed study quality and risk of bias. Each study was scored on collaborative care criteria: multi-professional approach to patient care, structured management plan, scheduled patient follow-ups and enhanced interprofessional communication. Thirty-five studies were included. Most trials studied the effect of cognitive behavioural therapy and interpersonal psychotherapy on antenatal depression. Almost all interventions met at least one collaborative care criteria. Interventions were mostly provided by multiple professionals, but interprofessional communication rarely took place. Interventions that met more criteria did not more often show a positive effect on maternal mental health. There is lack of research on antenatal psychiatric disorders other than depressive and on long-term treatment outcomes. Collaborative care is partly implemented in most current interventions, but more trials (including interprofessional communication) are needed to be conclusive whether collaborative care is a key component in antenatal mental healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00737-022-01251-7.

Keywords: Pregnancy, Mental disorders, Psychosocial, Collaborative care

Introduction

Globally, mental disorders during pregnancy are common, with prevalence rates of depressive and anxiety disorders around 20% (Woody et al. 2017; Ross and Dennis 2009, Yin et al. 2021). Women disadvantaged by psychosocial problems (low-income, minority status, unsafe (home) situation, living place in a deprived area, substance use disorder) are even more likely to develop depressive disorders (Ogbo et al. 2018; Redshaw and Henderson 2013). The prevalence rate in this population lies between 5 and 47% (Ross and Dennis 2009, Bennett et al. 2004). Mood and anxiety disorders do not only affect pregnant women by increasing the risk of postpartum depression and psychosis, but also have negative effects on the (unborn) child. These are risk factors for caesarean section, low birthweight and behavioural problems in late childhood (Jarde et al. 2016; Yedid Sion et al. 2016; Lee et al. 2007; Leis et al. 2014). There is growing evidence showing that mental disorders during pregnancy are common and have long-lasting consequences.

Current treatment options for antenatal depressive and anxiety disorders can be broadly divided into psychotherapy and pharmacotherapy. Because antenatal use of medication (e.g. antidepressants and/or anxiolytics) may have adverse effects on the (unborn) child (e.g. transient neonatal symptoms, congenital abnormalities and risk of pre-term birth), clinicians and women often prefer psychotherapy (Pearlstein 2015). Studies show that cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) can be effective in reducing antenatal depressive and anxiety symptoms (Sockol 2015; Sockol 2018). However, these therapies seem less effective for women with additional psychosocial problems (Nillni et al. 2018). Also, there is limited evidence of the long-lasting effects. Several barriers concerning the organization of care are identified on patient (e.g. stigma), provider (e.g. lack of expertise) and healthcare level (e.g. limited access to mental health treatment) (Byatt et al. 2012). Of all pregnant women diagnosed with a mental disorder, less than 10% receive adequate treatment (antidepressants or psychotherapy for > 6 weeks) and less than 5% achieve remission of psychiatric symptoms (Cox et al. 2016). Women with additional psychosocial problems are even less likely to engage in treatment (Grote et al. 2007). These factors make treating pregnant women with mental disorders challenging.

Collaboration between mental healthcare workers and obstetric care professionals may help overcome these challenges. Research has shown that collaborative care in other fields, like primary mental health care, is effective in improving psychiatric symptoms and adherence to treatment (Thota et al. 2012; Archer et al. 2012). Collaborative care in the obstetric care setting is a multidisciplinary treatment approach consisting of obstetricians, midwives, psychiatrists and psychologists (and social workers). (Gunn et al. 2006) designed a framework that identifies key components of collaborative care. Systematic reviews have used this framework in mental healthcare settings. We adapted these criteria to the obstetric care setting, in order to score studied interventions on the following collaborative care criteria:

  1. A multi-professional approach to patient care

  2. A structured management plan

  3. Scheduled patient follow-ups

  4. Enhanced interprofessional communication

Whether collaborative care interventions are effective in treating antenatal mental disorders is unknown. The aim of this study is to review antenatal mental health interventions, assess the level of collaboration and describe the impact of the different quality levels, measured by the collaborative care criteria (CCC), on maternal mental health outcomes.

Materials and methods

This systematic review is carried out according to the PRISMA guidelines.

Search strategy and study selection

We searched for randomized controlled trials, published in peer-reviewed journals, in the databases PubMed, Embase and PsycINFO. The following search terms, based on a previous review by LvR (Ravesteyn et al. 2017) and on clinical judgement, were used to identify eligible articles (see online resource 1): (1) pregnancy, (2) mental disorders, (3) psychosocial problems, (4) treatment and (5) randomized controlled trials. We used subject headings and free text terms. The search was conducted on 31 January 2020 and updated on 20 December 2021. We exported the results to EndNote and removed duplicates. Two authors (CK, LvR) reviewed the title and abstract for concept validity and excluded abstracts deemed to be irrelevant. In case of disagreement or doubt, a third reviewer was consulted (JS). Based on the selection criteria described below, full text articles were assessed. When there were multiple articles from the same trial, the article with the most complete or relevant outcomes was included.

Selection criteria

We included randomized controlled trials from database inception through December 20, 2021, if they.

  1. included pregnant women diagnosed with a mental disorder according to a standardized diagnostic interview based on the DSM or ICD criteria or pregnant women with clinical psychiatric symptoms according to validated mental health questionnaires (e.g. EPDS ≥ 10). Women with and without additional psychosocial problems (low-income, minority status, unsafe (home) situation, living place in a deprived area, substance use disorder) were included.

  2. studied a psychological or pharmacological treatment and provided face-to-face or over the telephone by one or more professional healthcare workers (e.g. midwife, obstetrician, psychiatrics, psychologist). Psychological interventions provided by a midwife or obstetrician were also included.

  3. examined any of the following maternal mental health outcomes: psychiatric symptoms (validated questionnaires, e.g. EPDS, STAI), incidence rates, recovery rates or risk reduction of psychiatric disorders. Secondary outcomes are any birth, neonatal, infant or biomarker outcome.

We excluded non-English studies, abstracts, case reports and studies including postpartum women. Also, studies on solely transcranial stimulation, food supplements, eHealth, physical treatment and interventions provided by informal health workers (e.g. lay health worker, peer support) were excluded.

Data extraction and analysis

The following details of each study were extracted and described in a summary table: first author, country, setting, (number of) participants, (duration of the) intervention, control condition, maternal mental health outcome and retention and compliance rates. The retention rate is calculated as the percentage of women who remained till the latest follow-up and the compliance rate as the percentage of women who attended all sessions of all women allocated to the intervention group. Birth, neonatal and infant outcomes are separately described.

First, the extracted data was analysed to create an overview of the effect of the interventions for different psychiatric disorders. Second, the data was analysed to assess the collaborative care criteria (CCC) and collaborative care scores (CCS). The CCC are defined and scored (by author CK) as follows (Gunn et al. 2006):

  1. A multi-professional approach to patient care: Care provided by a midwife or gynaecologist and at least one other healthcare professional (e.g. psychiatrist, psychologist, social worker, psychiatric nurse).

  2. Structured management plan: Evidence-based management plan according to the NICE or Marcé guideline or national guidelines derived from these (NICE 2014; Yonkers et al. 2009).

  3. Scheduled patient follow-ups: One or more telephone or in-person follow-up appointments are scheduled during or after treatment to provide specific interventions, facilitate treatment adherence or monitor symptoms or adverse effects (e.g. calls between sessions, evaluation of treatment goals, follow-up or booster sessions). Monitoring symptoms for research purposes was insufficient to meet this criterion. Also, active outreach for women who missed sessions and providing telephone sessions for women who missed a session was insufficient.

  4. Enhanced interprofessional communication: Team meetings, case-conferences, individual consultation/supervision, shared medical records, patient-specific written or verbal feedback between caregivers. Communication to check whether all involved therapists work according to the same instructions was not scored.

We contacted authors for additional information on CCC, when certain information was missing or unclear (n = 13, 3 replies). The CCS is the total number of criteria met by an intervention, and we described the relation between the CCS and the effect of the intervention on maternal mental health. The effect of the intervention was cited as positive ( +) when maternal mental health was significantly better in (a part of) the intervention group compared to the control group at ≥ 1 follow-up moment. The score was + / − when there was not a significant difference between both groups and negative ( −) when the maternal mental health was significantly worse in the intervention group compared to the control group.

Quality assessment

To assess the methodological quality of the included studies we used the Cochrane risk-of-bias tool for randomized trials (Higgins et al. 2011). The quality of all studies was assessed on the following domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective reporting. Each item was rated as low, unclear or high risk of bias. Studies were classified as high quality (not fulfilling 0–1 criterion), moderate (not fulfilling 2–3 criteria) and low quality (not fulfilling > 3 criteria).

Results

Study characteristics

Two thousand seventy hundred forty-six records were identified, of which 171 were assessed for eligibility based on title and abstract; 47 articles met the inclusion criteria (see Fig. 1 flow diagram). These articles describe 35 different multi-outcome trials, published between 2000 and 2021 (see online resource 2).

Fig. 1.

Fig. 1

Open in a new tab

Flow diagram

Depression was the most common studied mental disorder (k = 23), followed by a combination of depression and anxiety (k = 5), insomnia (k = 3) and tocophobia (k = 3). One study (k = 1) focused on a variety of psychiatric and personality disorders. Of all studies, 16 included women with a combination of psychiatric symptoms and psychosocial risk factors (e.g. low socio-economic status, deprived area). CBT (k = 15) and IPT (k = 6) were the most studied interventions. Other interventions studied more than once were psychoeducation (k = 4), mindfulness-based therapy (k = 4) and multicomponent therapy (k = 2). There were no studies on pharmacotherapy only. A considerable part of the interventions (k = 15) was provided to groups of women. The number of sessions varied between 2 to 16 sessions, which were mostly provided once a week.

Depression and anxiety

Cognitive behavioural therapy (CBT)

Most included RCT’s (k = 12) investigated the effect of CBT on antenatal depression. Part of the studies (k = 6) examined individual CBT (6–14 sessions) modified to pregnant women, focusing on the specific problems these women were facing. Three pilot studies (Cho et al. 2008; Burns et al. 2013; Milgrom et al. 2015) found significantly lower levels of depressive or anxiety symptoms in the CBT group compared to the care as usual group. Of the 3 larger trials, one study (Bittner et al. 2014) found an intervention effect for women with high depressive symptoms, one study (Austin et al. 2008) described no significant effect, and one study (Burger et al. 2020) showed a negative effect of CBT compared to usual care. The other 6 studies examined CBT modified to women with additional psychosocial problems (e.g. low-income, minority group). Four studies (O'Mahen et al. 2013; Alhusen et al. 2021; Le et al. 2011; Jesse et al. 2015), including two pilot studies (O'Mahen et al. 2013; Alhusen et al. 2021), reported (significantly) lower depressive symptoms in the CBT group compared to the care as usual group. However, one of these study (Jarde et al. 2016, 2015) found a treatment effect for high-risk African American women only, and one study was not powered to test for statistical significance. The other 2 studies, (Muñoz et al. 2007) did not find a significant difference between both groups.

Interpersonal therapy (IPT)

Overall, 4 studies (Spinelli and Endicott 2003; Zlotnick et al. 2006; Zlotnick et al. 2016; Grote et al. 2009) concluded that IPT (4–16 sessions) was more effective than usual care or a parenting education programme. The other 2 studies (Spinelli et al. 2013; Lenze et al. 2020) did not report a significant effect. All interventions were provided to women with both psychiatric and psychosocial problems. A recently published pilot study compared IPT with CBT, which both showed a positive effect on depressive symptoms (Evans et al. 2021).

Psychoeducation

Both studies on psycho-education (Lara et al. 2010; Zhao et al. 2019) (6–8 sessions) showed a significantly positive effect on depression rates or symptoms compared to care as usual and the self-help book only group.

Mindfulness-based therapy

Three articles (Yazdanimehr et al. 2016; Zemestani, et al. 2020; Lönnberg et al. 2020) described mindfulness-based interventions (e.g. CBT, mindfulness-based childbirth and parenting group), which all showed positive findings concerning depressive and/or anxiety symptoms compared to usual care.

Multicomponent therapy

Two RCT’s (Grote et al. 2015; Ravesteyn et al. 2018) examined the effect of a multicomponent treatment provided by a multi-disciplinary team. An intervention47 providing the choice of brief IPT and/or pharmacotherapy revealed a significantly positive effect compared to care as usual. A combination of weekly CBT, psychoeducation, body-oriented and relaxation therapy48 was signifcantly not more effective than individual counselling sessions.

Other psychological therapies

Both problem-solving skills training (Khamseh et al. 2019) (5 sessions) and behavioural activation (Dimidjian et al. 2017) (10 sessions) were reported as effective in reducing depressive (and anxiety) symptoms. A group preventive risk-reducing treatment to prevent postpartum depression (Brugha et al. 2000) and psychosomatic programming (Ortiz Collado et al. 2014) did not reveal a significant effect of the intervention compared to usual care.

Insomnia

Three studies (Manber et al. 2019; Rezaei et al. 2015; Khatibi et al. 2021) showed that treating insomnia might lead to reduction of depressive symptoms. Both, 5 individual sessions of CBT and 4 sessions of group behavioural sleep education, significantly reduced depressive symptoms during pregnancy.

Tocophobia

Two sessions of telephone psychoeducation by a midwife (Toohill et al. 2014) as well as cognitive therapy for tocophobia (Saisto et al. 2001) significantly reduced the level of fear of childbirth or birth-related concerns compared to written information about childbirth. Also, mindfulness-based childbirth and parenting group sessions (Veringa-Skiba et al. 2021) led to significantly lower levels of fear of childbirth compared to enhanced care as usual.

Secondary outcomes

Positive effects of perinatal interventions on birth, neonatal and infant outcomes are described (e.g. reduction of preterm birth rate, lower caesarean rate, higher scores on self-regulation and stress-reactivity at 9 months) (see online resource 3).

Collaborative care score

Table 1 shows an overview of the CCC of all studies. Of the 35 studies, 33 interventions met at least 1 criterion, and most studies met 2 criteria. A multi-professional approach to patient care was the most scored, and interprofessional communication was the least scored criterion. Of the 35 studies, 6 studies met all CCC. The studies with high CCS scores of 3 or 4 (n = 13) were all based on a structured management plan according to NICE or Marcé guidelines (CBT, IPT, multicomponent, psychoeducation) and provided by multiple professionals to depressive women. All interventions with a score of 4 were provided to women with additional psychosocial risk factors. Whereas the CCS 3 studies provided follow-up sessions after treatment only, the CCS 4 studies provided more often follow-up sessions during treatment. Also, more professionals were involved in the CCS 4 studies (2 to 6 professionals) than in CCS 3 studies (2 professionals). Of the 29 multi-professional interventions, 25 interventions were provided by a gynaecologist/midwife and a mental health therapist. The other 4 interventions were provided by a team of 3 to 6 different professionals. All 4 studies provided by one professional were provided by midwifes and/or obstetricians (and not by a mental health worker).

Table 1.

The collaborative care criteria and collaborative care scores sorted by intervention/diagnosis from a high to a low CCS score

Study Structured management plan (* = Not according to NICE/Marcé guideline) Professional (n + gyna) Scheduled patient follow-ups Enhanced interprofessional communication CCS
El-Mohandes CBT 1 2 booster sessions Individual consultation, supervision 4
Jesse CBT (group) 3 Weekly booster session telephone calls Individual consultation, shared medical records 4
Le CBT (psycho-educational, group) 1 3 individual booster sessions Team meetings 4
Austin CBT (group) 1 Follow-up session 3
Burger CBT 1 Sessions up to 3 months postpartum 3
Cho CBT 1 In the final session plans for follow-up were discussed 3
Muñoz CBT (group) 1 4 booster sessions 3
Alhusen CBT (group) 1 2
Bittner CBT (group) 1 2
Burns CBT 1 2
Milgrom CBT 1 2
O’mahen CBT 1 2
Yazdanimehr CBT (mindfulness) 1 2
Zemestani CBT (mindfulness, group) 1 2
Khatibi CBT Unknown 1
Lenze IPT 1 Contact between sessions, postpartum sessions Team meetings, supervision 4
Grote (09) IPT 1 Maintenance sessions up to 6 months postpartum 3
Zlotnick IPT (group) 1 Booster session 3
Evans IPT 1 2
Spinelli (03) IPT 1 2
Spinelli (13) IPT 1 2
Grote (15) Multicomponent (choice of IPT or antidepressant) 3 Telephone sessions, in-person visits up to 18 months Team meetings 4
Van Ravesteyn Multicomponent (group) 5 Weekly evaluation of treatment goals Team meetings 4
Lara Psychoeducation (group)b 1 2 individual booster sessions, calls between sessions 3
Zhao *Psychoeducation (group)b 1 Continuous support between sessions (individual counselling via telephone or email) 2
Manber CBT (insomnia) 1 2
Rezeai Behavioural health sleep education (group, insomnia) Unknown 1
Saisto Cognitive therapy (tocophobia) - 1
Toohill *Telephone psychoeducation (tocophobia) - 0
Veringa *Mindfulness-based childbirth/parenting (group, tocophobia) - 0
Brugha *Preventative risk-reducing treatment (group) 1 Reunion class 2
Dimidjian Behavioural activation 1 2
Khamseh *Problem-solving skills training 3 Team meetings, individual consultation, verbal feedback 2
Lönnberg *Mindfulness-based childbirth/parenting (group) 1 Reunion session 2
Ortiz *Psychosomatic programming - Between sessions a follow-up phone call 1
Open in a new tab

aThe number of different involved professionals besides a gynaecologist or midwife

bPsychoeducation with the provision of a manual (information, working forms, checklists) meets the criteria for facilitated self-help, described as an evidence-based management plan (NICE guideline). Without the provision of a self-help manual, psychoeducation is not described as an evidence-based management plant

Impact collaborative care score

Studies with a CCS of 2 showed the most interventions (k = 14) with a positive effect on maternal mental health (see Table 2 and more extensive in online resource 4). Interventions with higher scores did not show a positive effect more often than interventions with lower scores. Of the 24 interventions with a positive effect, 20 studies met the criterion of a multi-professional approach to patient care. The retention and compliance rates are also described in Table 2. These do not show a clear pattern. However, all studies with the highest retention rates of ≥ 90% (k = 7) and studies with the highest compliance rates of ≥ 60% (k = 6) met the criterion of a multi-professional approach to patient care. The few studies that scored on interprofessional communication had predominantly high retention and compliance rates. Although a higher CCS did not always show a positive effect or higher retention and compliance rates, almost all interventions with a positive effect on maternal mental health and with high retention and compliance rates met the criterion of a multi-professional approach to patient care.

Table 2.

The relation between the collaborative care score and the effect of the intervention on maternal mental health and retention and compliance rates; the CCC score is the total number of collaborative care criteria met by an intervention

CCC score 0 1 2 3 4
Positive effect intervention Veringa-Skiba Toohill Khatibi Rezeai

Alhusen

Bittner

Burns

Dimidjian

Evans

Khamseh

Lönnberg

Manber

Milgrom

O’Mahen

Spinelli (03)

Yazdanimehr

Zemestani

Zhao

Cho

Grote (09)

Lara

Zlotnick

Grote (15)

Jesse

Le
No difference Ortiz Saisto Brugha Spinelli (13) Austin Mūnoz El-Mohandes Lenze Ravesteyn
Negative effect intervention Burger
Retention rate range (%) 75 59–89 45–100 31–91 56–98
Compliance rate range (%) 21 54 23–100 49–80 43–84
Open in a new tab

Study quality

Most studies had a medium risk of bias, due to insufficiently describing one or more criteria, leading to an unclear risk of bias (see online resource 5). Blinding of participants and personnel to the given intervention was most times impossible, which could have led to a high risk of performance bias. Additionally, most outcomes were self-reported measures, which could have attributed to the risk of bias when participants were not blinded for the intervention.

Discussion

Main findings

The aim of this study was to give a systematic overview of all current antenatal mental health interventions and to describe the role of collaborative care. The current available interventions are almost all either based on a structured management plan according to NICE or Marcé or multidisciplinary, which means almost all studies met at least one collaborative care criterion. Interventions with a higher collaborative care score did not more often show a positive effect on maternal mental health.

Almost all included trials (n = 28) focused on treating women at risk of a depressive disorder. CBT and IPT were the most studied interventions. Both therapies were predominantly effective in reducing depressive and anxiety symptoms. The effects of other interventions are based on a few trials with small numbers of participants. Potentially beneficial interventions are mindfulness-based therapy (3 trials), multicomponent treatment (2 trials), psychoeducation (2 trials) and behavioural activation (1 trial). The results of the few studies on tocophobia and insomnia showed promising findings in reducing depressive symptoms and symptoms of fear.

Although we could not find a clear effect of the CCS on maternal mental health, we did find that a multi-professional approach to patient care could be essential in the treatment of pregnant women with psychiatric and psychosocial problems. Almost all interventions with a positive effect on maternal mental health and all studies with high retention (≥ 90%) and compliance (≥ 60%) rates met this criterion. However, it was also the most common CCC, which could have had impact on its perceived prevalence in positive outcome studies. Interventions provided by a multi-professional team consisting of more than 2 different professionals (> gynaecologist/midwife and a mental health therapist) were rare, as well as interprofessional communication which was the least scored criterion.

Strength and limitations

This review extends the literature about the challenges in antenatal mental health care (Nillni et al. 2018; Ravesteyn et al. 2017; Dennis 2005) by giving a new broad overview of current available therapies in this field and describing the role of collaborative care in this treatment. We limited our study to RCT’s only; therefore, we could have missed other potentially contributing studies. CBT and IPT were the most studied interventions, but we found a high heterogeneity within these interventions (e.g. content and number of sessions). Due to the focus on collaborative care instead of intervention and outcome protocols, the heterogeneity between studies is not fully classified in the results section. Also, the studies occurred across the world, in different healthcare systems and over a 20-year span, during which the antenatal care field, including collaborative care, was rapidly evolving. Retention and compliance rates were difficult to compare, because of the variation in the number of provided sessions and the time of follow-up. Another limitation is that the method of this study partly relied on the additional information on CCC send by authors, which could have led to an underestimation of the CCS’s because not all authors responded. Last, we included two pilot studies that were not powered to test for statistical significance.

Interpretation

To our knowledge, this is one of the first reviews about collaborative care in the setting of antenatal mental health care. Research in antenatal mental health care mainly focuses on the effect of psychotherapy on depressive symptoms. The predominantly positive findings of CBT and IPT are in line with previous research that showed that CBT and IPT—interventions advised by the NICE guideline—are effective in treating antenatal depression (Sockol 2015; Sockol 2018; Nillni et al. 2018). The treatment of women with additional psychosocial problems, resembling clinical practice, is less studied. A systematic review of (Nillni et al. 2018) about the antenatal treatment of depression and anxiety disorders also included women with psychosocial problems. However, this review showed, unlike our review, mixed findings of both CBT and IPT in this population. Especially, the interventions with a high CCS focused on this population. This could mean that a high CCS can have a positive effect in populations with additional psychosocial problems.

As already noted, collaborative care in primary care setting is effective in improving psychiatric symptoms and adherence to treatment (Thota et al. 2012; Alhusen et al. 2021, 2012, Gunn et al. 2006). In obstetrics setting, a previous review of qualitative and quantitative studies concluded that professionals in the antenatal field are supportive of increased collaboration with other professionals because of the expected benefits for mother and child (Myors et al. 2013). Key components were identified to make this process happen, like funding and resources for collaboration, guidelines and training and education of staff. (Melville et al. 2014) conducted an RCT, in which a multidisciplinary care intervention adapted to obstetrics and gynaecology clinics was studied. The study reported a greater improvement in psychiatric symptoms, better adherence to treatment and a greater satisfaction with care than in the usual care group. Although there is limited evidence about the role of collaborative care in the antenatal mental healthcare setting, this review showed the developments in the field, because almost all interventions were provided by multiple professionals. However, interventions provided by multidisciplinary teams of more than 2 different professionals (e.g. social worker) are rare. Also, remarkable is that just a few studies met the criterion of interprofessional communication. That means that obstetric and mental healthcare professionals were most times both involved, but that communication, in a structured way, between them often did not take place or was not reported. Further research should focus on the effect of communication and collaboration between the different professionals, which will enable personalized medicine, including shared decision-making between the patient and the different involved caregivers. Both are important in (mental) health care and will eventually lead to improved treatment adherence and more meaningful outcomes for the patient (Drake et al. 2009). Because of the low number of trials that met all collaborative care criteria, more trials are needed, to make a clear conclusion about the impact of collaborative care on maternal mental health and treatment adherence.

Last, this review shows which evidence is missing in the field of antenatal mental health care. Almost all studies were about interventions provided to women with depressive symptoms. Despite the high incidence of anxiety symptoms during pregnancy, just 5 trials focused on women at risk of depression and anxiety. Only 3 trials were about women with tocophobia or insomnia. This shows there is a clear need for more trials on psychiatric disorders other than depression. Additionally, more research to interventions except from CBT and IPT could lead to positive consequences in the field. For example, promising results of mindfulness-based therapy were found in this review. Although there is raising awareness for child and partner outcomes, almost all current outcomes are short-term mother or birth outcomes. Because of the negative long-term effects of antenatal mental health disorders, for future research, it is recommended to examine long-term outcomes of the whole family system, so mother, partner and child.

Conclusions

In conclusion, there is an important lack of evidence in the field of antenatal mental health care. Available evidence focuses on studies evaluating CBT and IPT for treating antenatal depression. More research is recommended on other psychiatric disorders, interventions and long-term follow-up outcomes. Additionally, collaborative care and especially a multi-professional approach to patient care are already implemented in most available interventions. However, interprofessional communication and multidisciplinary teams of more than two different professionals are rare. More trials are needed on the impact of interprofessional communication and on the mechanisms by which collaborative care meets antenatal mental health needs to be more conclusive whether and in which way collaborative care is a key component in antenatal mental health care.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 19 KB) (19.3KB, docx)
Supplementary file2 (DOCX 1299 KB) (1.3MB, docx)
Supplementary file3 (DOCX 1283 KB) (1.3MB, docx)
Supplementary file4 (DOCX 25 KB) (24.8KB, docx)
Supplementary file5 (DOCX 1408 KB) (1.4MB, docx)

Author contribution

CK Klatter: data collection (screening abstracts and selecting eligible trials), data extraction and analysis, methodological assessment, manuscript writing.

LM van Ravesteyn: data collection, data extraction, methodological assessment, manuscript editing.

J Stekelenburg: supervision data collection and analysis, manuscript editing.

Declarations

Conflict of interest

The authors declare no competing interests.

Footnotes

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. Alhusen JL, Hayat MJ, Borg L. A pilot study of a group-based perinatal depression intervention on reducing depressive symptoms and improving maternal-fetal attachment and maternal sensitivity. Arch Womens Ment Health. 2021;24(1):145–154. doi: 10.1007/s00737-020-01032-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012 doi: 10.1002/14651858.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Austin MP, Frilingos M, Lumley J, Hadzi-Pavlovic D, Roncolato W, Acland S, et al. Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial. J Affect Disord. 2008;105(1–3):35–44. doi: 10.1016/j.jad.2007.04.001. [DOI] [PubMed] [Google Scholar]
  4. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 2004;103(4):698–709. doi: 10.1097/01.aog.0000116689.75396.5f. [DOI] [PubMed] [Google Scholar]
  5. Bittner A, Peukert J, Zimmermann C, Junge-Hoffmeister J, Parker LS, Stöbel-Richter Y. Early intervention in pregnant women with elevated anxiety and depressive symptoms: efficacy of a cognitive-behavioral group program. J Perinat Neonatal Nurs. 2014;28(3):185–195. doi: 10.1097/jpn.0000000000000027. [DOI] [PubMed] [Google Scholar]
  6. Bleker LS, Milgrom J, Sexton-Oates A, Roseboom TJ, Gemmill AW, Holt CJ, et al. Exploring the effect of antenatal depression treatment on children’s epigenetic profiles: findings from a pilot randomized controlled trial. Clin Epigenetics. 2019;11(1):18. doi: 10.1186/s13148-019-0616-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brugha TS, Wheatley S, Taub NA, Culverwell A, Friedman T, Kirwan P, et al. Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors. Psychol Med. 2000;30(6):1273–1281. doi: 10.1017/s0033291799002937. [DOI] [PubMed] [Google Scholar]
  8. Burger H, Verbeek T, Aris-Meijer JL, Beijers C, Mol BW, Hollon SD, et al. Effects of psychological treatment of mental health problems in pregnant women to protect their offspring: randomised controlled trial. Br J Psychiatry. 2020;216(4):182–188. doi: 10.1192/bjp.2019.260. [DOI] [PubMed] [Google Scholar]
  9. Burns A, O'Mahen H, Baxter H, Bennert K, Wiles N, Ramchandani P, et al. A pilot randomised controlled trial of cognitive behavioural therapy for antenatal depression. BMC Psychiatry. 2013;22(13):33. doi: 10.1186/1471-244x-13-33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Byatt N, Simas TA, Lundquist RS, Johnson JV, Ziedonis DM. Strategies for improving perinatal depression treatment in North American outpatient obstetric settings. J Psychosom Obstet Gynaecol. 2012;33(4):143–161. doi: 10.3109/0167482x.2012.728649. [DOI] [PubMed] [Google Scholar]
  11. Cho HJ, Kwon JH, Lee JJ. Antenatal cognitive-behavioral therapy for prevention of postpartum depression: a pilot study. Yonsei Med J. 2008;49(4):553–562. doi: 10.3349/ymj.2008.49.4.553. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The perinatal depression treatment cascade: baby steps toward improving outcomes. J Clin Psychiatry. 2016;77(9):1189–1200. doi: 10.4088/jcp.15r10174. [DOI] [PubMed] [Google Scholar]
  13. Dennis CL (2005) Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. BMJ 331(7507):15. 10.1136/bmj.331.7507.15 [DOI] [PMC free article] [PubMed]
  14. Dimidjian S, Goodman SH, Sherwood NE, Simon GE, Ludman E, Gallop R, et al. A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women. J Consult Clin Psychol. 2017;85(1):26–36. doi: 10.1037/ccp0000151. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Drake RE, Cimpean D, Torrey WC (2009) Shared decision making in mental health: prospects for personalized medicine. Dialogues Clin Neurosci 11(4):455–63. 10.31887/dcns.2009.11.4/redrake [DOI] [PMC free article] [PubMed]
  16. El-Mohandes AA, Kiely M, Joseph JG, Subramanian S, Johnson AA, Blake SM, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol. 2008;112(3):611–620. doi: 10.1097/aog.0b013e3181834b10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. El-Mohandes AA, Kiely M, Gantz MG, El-Khorazaty MN. Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial. Matern Child Health J. 2011;15(1):19–28. doi: 10.1007/s10995-009-0557-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Evans J, Ingram J, Law R, Taylor H, Johnson D, Glynn J, et al. Interpersonal counselling versus perinatal-specific cognitive behavioural therapy for women with depression during pregnancy offered in routine psychological treatment services: a phase II randomised trial. BMC Psychiatry. 2021;21(1):504. doi: 10.1186/s12888-021-03482-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Grote NK, Zuckoff A, Swartz H, Bledsoe SE, Geibel S. Engaging women who are depressed and economically disadvantaged in mental health treatment. Soc Work. 2007;52(4):295–308. doi: 10.1093/sw/52.4.295. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Grote NK, Swartz HA, Geibel SL, Zuckoff A, Houck PR, Frank E. A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression. Psychiatr Serv. 2009;60(3):313–321. doi: 10.1176/appi.ps.60.3.313. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Grote NK, Katon WJ, Russo JE, Lohr MJ, Curran M, Galvin E, et al. Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depress Anxiety. 2015;32(11):821–834. doi: 10.1002/da.22405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Gunn J, Diggens J, Hegarty K, Blashki G. A systematic review of complex system interventions designed to increase recovery from depression in primary care. BMC Health Serv Res. 2006;6:88. doi: 10.1186/1472-6963-6-88. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Higgins J, Altman D, Gotzsche P, Juni P, Moher D, Oxman A, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928–d5928. doi: 10.1136/bmj.d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Jarde A, Morais M, Kingston D, Giallo R, MacQueen GM, Giglia L, et al. Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis. JAMA Psychiat. 2016;73(8):826837. doi: 10.1001/jamapsychiatry.2016.0934. [DOI] [PubMed] [Google Scholar]
  25. Jesse DE, Gaynes BN, Feldhousen EB, Newton ER, Bunch S, Hollon SD. Performance of a culturally tailored cognitive-behavioral intervention integrated in a public health setting to reduce risk of antepartum depression: a randomized controlled trial. J Midwifery Womens Health. 2015;60(5):578–592. doi: 10.1111/jmwh.12308. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Khamseh F, Parandeh A, Hajiamini Z, Tadrissi SD, Najjar M. Effectiveness of applying problem-solving training on depression in Iranian pregnant women: randomized clinical trial. J Educ Health Promot. 2019;8:87. doi: 10.4103/jehp.jehp_270_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Khatibi S, Kazemi M, Zenoozian S, Vakili M, Kharaghani R (2021) Cognitive behavioral counseling and sleep quality in pregnant women: a randomized controlled trial current sleep medicine reports 7(3):120–128. 10.1007/s40675-021-00213-2
  28. Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord. 2010;122(1–2):109–117. doi: 10.1016/j.jad.2009.06.024. [DOI] [PubMed] [Google Scholar]
  29. Le HN, Perry DF, Stuart EA. Randomized controlled trial of a preventive intervention for perinatal depression in high-risk Latinas. J Consult Clin Psychol. 2011;79(2):135–141. doi: 10.1037/a0022492. [DOI] [PubMed] [Google Scholar]
  30. Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol. 2007;110(5):1102–1112. doi: 10.1097/01.aog.0000287065.59491.70. [DOI] [PubMed] [Google Scholar]
  31. Leis JA, Heron J, Stuart EA, Mendelson T. Associations between maternal mental health and child emotional and behavioral problems: does prenatal mental health matter? J Abnorm Child Psychol. 2014;42(1):161–171. doi: 10.1007/s10802-013-9766-4. [DOI] [PubMed] [Google Scholar]
  32. Lenze SN, Potts MA, Rodgers J, Luby J. Lessons learned from a pilot randomized controlled trial of dyadic interpersonal psychotherapy for perinatal depression in a low-income population. J Affect Disord. 2020;271:286–292. doi: 10.1016/j.jad.2020.03.084. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Lönnberg G, Jonas W, Unternaehrer E, Bränström R, Nissen E, Niemi M. Effects of a mindfulness-based childbirth and parenting program on pregnant women’s perceived stress and risk of perinatal depression-results from a randomized controlled trial. J Affect Disord. 2020;262:133–142. doi: 10.1016/j.jad.2019.10.048. [DOI] [PubMed] [Google Scholar]
  34. Manber R, Bei B, Simpson N, Asarnow L, Rangel E, Sit A, et al. Cognitive behavioral therapy for prenatal insomnia: a randomized controlled trial. Obstet Gynecol. 2019;133(5):911–919. doi: 10.1097/aog.0000000000003216. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Melville JL, Reed SD, Russo J, Croicu CA, Ludman E, LaRocco-Cockburn A, et al. Improving care for depression in obstetrics and gynecology: a randomized controlled trial. Obstet Gynecol. 2014;123(6):1237–1246. doi: 10.1097/aog.0000000000000231. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Milgrom J, Holt C, Holt CJ, Ross J, Ericksen J, Gemmill AW. Feasibility study and pilot randomised trial of an antenatal depression treatment with infant follow-up. Arch Womens Ment Health. 2015;18(5):717–730. doi: 10.1007/s00737-015-0512-5. [DOI] [PubMed] [Google Scholar]
  37. Muñoz R, Le H, Ippen C, Diaz M, Urizar G, Soto J, et al. Prevention of postpartum depression in low-income women: development of the mamás y bebés/mothers and babies course. Cogn Behav Pract. 2007;14(1):70–83. doi: 10.1016/j.cbpra.2006.04.021. [DOI] [Google Scholar]
  38. Myors KA, Schmied V, Johnson M, Cleary M. Collaboration and integrated services for perinatal mental health: an integrative review. Child Adolesc Ment Health. 2013;18(1):1–10. doi: 10.1111/j.1475-3588.2011.00639.x. [DOI] [PubMed] [Google Scholar]
  39. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. NICE; 2014 [updated 2020 Febr; cited 2020 Sept]. Available from: www.nice.org.uk/guidance/cg192 [PubMed]
  40. Netsi E, Evans J, Wulff K, O'Mahen H, Ramchandani PG. Infant outcomes following treatment of antenatal depression: Findings from a pilot randomized controlled trial. J Affect Disord. 2015;188:252–256. doi: 10.1016/j.jad.2015.08.055. [DOI] [PubMed] [Google Scholar]
  41. Nillni YI, Mehralizade A, Mayer L, Milanovic S. Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: a systematic review. Clin Psychol Rev. 2018;66:136–148. doi: 10.1016/j.cpr.2018.06.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Ogbo FA, Eastwood J, Hendry A, Jalaludin B, Kingsley EA, Barnett B, et al. Determinants of antenatal depression and postnatal depression in Australia. BMC Psychiatry. 2018;18(1):49. doi: 10.1186/s12888-018-1598-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. O'Mahen H, Himle JA, Fedock G, Henshaw E, Flynn H. A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes. Depress Anxiety. 2013;30(7):679–687. doi: 10.1002/da.22050. [DOI] [PubMed] [Google Scholar]
  44. Ortiz Collado MA, Saez M, Favrod J, Hatem M. Antenatal psychosomatic programming to reduce postpartum depression risk and improve childbirth outcomes: a randomized controlled trial in Spain and France. BMC Pregnancy Childbirth. 2014;14:22. doi: 10.1186/1471-2393-14-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Pearlstein T. Depression during pregnancy. Best Pract Res Clin Obstet Gynaecol. 2015;29(5):754–764. doi: 10.1016/j.bpobgyn.2015.04.004. [DOI] [PubMed] [Google Scholar]
  46. Pearson RM, O'Mahen H, Burns A, Bennert K, Shepherd C, Baxter H, et al. The normalisation of disrupted attentional processing of infant distress in depressed pregnant women following Cognitive Behavioural Therapy. J Affect Disord. 2013;145(2):208–213. doi: 10.1016/j.jad.2012.07.033. [DOI] [PubMed] [Google Scholar]
  47. Redshaw M, Henderson J. From antenatal to postnatal depression: associated factors and mitigating influences. J Womens Health (larchmt) 2013;22(6):518–525. doi: 10.1089/jwh.2012.4152. [DOI] [PubMed] [Google Scholar]
  48. Rezaei E, Behboodi Moghadam Z, Hagani H. The effect of sleep health behavioral education on the depression of pregnant women with sleep disorders: a randomized control trial. Iran Red Crescent Med J. 2015;17(1):e11420. doi: 10.5812/ircmj.11420. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Ross LE, Dennis CL. The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: a systematic review. J Womens Health (larchmt) 2009;18(4):475–486. doi: 10.1089/jwh.2008.0953. [DOI] [PubMed] [Google Scholar]
  50. Saisto T, Salmela-Aro K, Nurmi JE, Könönen T, Halmesmäki E. A randomized controlled trial of intervention in fear of childbirth. Obstet Gynecol. 2001;98:820–826. doi: 10.1016/s0029-7844(01)01552-6. [DOI] [PubMed] [Google Scholar]
  51. Sockol LE. A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. J Affect Disord. 2015;177:7–21. doi: 10.1016/j.jad.2015.01.052. [DOI] [PubMed] [Google Scholar]
  52. Sockol LE. A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women. J Affect Disord. 2018;232:316–328. doi: 10.1016/j.jad.2018.01.018. [DOI] [PubMed] [Google Scholar]
  53. Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry. 2003;160(3):555–562. doi: 10.1176/appi.ajp.160.3.555. [DOI] [PubMed] [Google Scholar]
  54. Spinelli MG, Endicott J, Leon AC, Goetz RR, Kalish RB, Brustman LE, et al. A controlled clinical treatment trial of interpersonal psychotherapy for depressed pregnant women at 3 New York City sites. J Clin Psychiatry. 2013;74(4):393–399. doi: 10.4088/jcp.12m07909. [DOI] [PubMed] [Google Scholar]
  55. Subramanian S, Katz KS, Rodan M, Gantz MG, El-Khorazaty NM, Johnson A, et al. An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes. Matern Child Health J. 2012;16(3):545–554. doi: 10.1007/s10995-011-0875-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012;42(5):525–538. doi: 10.1016/j.amepre.2012.01.019. [DOI] [PubMed] [Google Scholar]
  57. Toohill J, Fenwick J, Gamble J, Creedy DK, Buist A, Turkstra E, et al. A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women. Birth. 2014;41(4):384–394. doi: 10.1111/birt.12136. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. van Ravesteyn LM, Lambregtse-van den Berg MP, Hoogendijk WJ, Kamperman AM. Interventions to treat mental disorders during pregnancy: a systematic review and multiple treatment meta-analysis. PLoS ONE. 2017;12(3):e0173397. doi: 10.1371/journal.pone.0173397. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Van Ravesteyn LM, Kamperman AM, Schneider TAJ, Raats ME, Steegers EAP, Tiemeier H, et al. Group-based multicomponent treatment to reduce depressive symptoms in women with co-morbid psychiatric and psychosocial problems during pregnancy: a randomized controlled trial. J Affect Disord. 2018;226:36–44. doi: 10.1016/j.jad.2017.09.019. [DOI] [PubMed] [Google Scholar]
  60. Veringa-Skiba IK, de Bruin EI, van Steensel FJA, Bögels SM. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: a randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual. Birth. 2021;49(1):40–51. doi: 10.1111/birt.12571. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Woody CA, Ferrari AJ, Siskind DJ, Whiteford HA, Harris MG. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017;219:86–92. doi: 10.1016/j.jad.2017.05.003. [DOI] [PubMed] [Google Scholar]
  62. Yazdanimehr R, Omidi A, Sadat Z, Akbari H (2016) The effect of mindfulness-integrated cognitive behavior therapy on depression and anxiety among pregnant women: a randomized clinical trial. J Caring Sci 5(3):195–204. 10.15171/jcs.2016.021 [DOI] [PMC free article] [PubMed]
  63. Yedid Sion M, Harlev A, Weintraub AY, Sergienko R, Sheiner E. Is antenatal depression associated with adverse obstetric and perinatal outcomes? J Matern Fetal Neonatal Med. 2016;29(6):863–867. doi: 10.3109/14767058.2015.1023708. [DOI] [PubMed] [Google Scholar]
  64. Yin X, Sun N, Jiang N, Xu X, Gan Y, Zhang J, et al. Prevalence and associated factors of antenatal depression: systematic reviews and meta-analyses. Clin Psychol Rev. 2021;83:101932. doi: 10.1016/j.cpr.2020.101932. [DOI] [PubMed] [Google Scholar]
  65. Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703–713. doi: 10.1097/aog.0b013e3181ba0632. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Zemestani M, Fazeli Nikoo Z (2020) Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Arch Womens Ment Health 23(2):207–214. 10.1007/s00737-019-00962-8 [DOI] [PubMed]
  67. Zhao Y, Munro-Kramer ML, Shi S, Wang J, Luo J. A randomized controlled trial: effects of a prenatal depression intervention on perinatal outcomes among Chinese high-risk pregnant women with medically defined complications. Arch Womens Ment Health. 2017;20(2):333–344. doi: 10.1007/s00737-016-0712-7. [DOI] [PubMed] [Google Scholar]
  68. Zhao Y, Munro-Kramer ML, Shi S, Wang J, Zhao Q. Effects of antenatal depression screening and intervention among Chinese high-risk pregnant women with medically defined complications: a randomized controlled trial. Early Interv Psychiatry. 2019;13(5):1090–1098. doi: 10.1111/eip.12731. [DOI] [PubMed] [Google Scholar]
  69. Zlotnick C, Miller IW, Pearlstein T, Howard M, Sweeney P. A preventive intervention for pregnant women on public assistance at risk for postpartum depression. Am J Psychiatry. 2006;163(8):1443–1445. doi: 10.1176/ajp.2006.163.8.1443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Zlotnick C, Tzilos G, Miller I, Seifer R, Stout R. Randomized controlled trial to prevent postpartum depression in mothers on public assistance. J Affect Disord. 2016;189:263–268. doi: 10.1016/j.jad.2015.09.059. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary file1 (DOCX 19 KB) (19.3KB, docx)
Supplementary file2 (DOCX 1299 KB) (1.3MB, docx)
Supplementary file3 (DOCX 1283 KB) (1.3MB, docx)
Supplementary file4 (DOCX 25 KB) (24.8KB, docx)
Supplementary file5 (DOCX 1408 KB) (1.4MB, docx)

Articles from Archives of Women's Mental Health are provided here courtesy of Springer

RESOURCES