You Think You're Confused! Family Physicians' Attitudes about Maternal Mental Health'

Try being a primary care provider treating a pregnant woman who is on antidepressants.  Dr. Michael Klein’s recent S&S post [about his newly published research] aptly considered the power of attitudes and beliefs to shape practices and maintain problematic paradigms.  The same attitude-driven care dynamic is alive and well in the ongoing battle to understand perinatal mood disorders, and how to treat these disorders in pregnancy.

Primary care physician’s attitudes and practices regarding antidepressant use during pregnancy: A survey of two countries (Bilszta, Tsuchiya, Han, Buist, & Einarson, 2011) explored how lack of practice guidelines, and conflicting and confusing data makes it “difficult to provide definitive evidence-based information” (p. 71).  The study explored the primary care physician’s beliefs about perinatal depression as evidenced in their decision-making to continue or discontinue the use of antidepressant medication during pregnancy.  In addition, the authors surveyed PCP’s attitudes from two developed countries, Australia and Canada, where physician awareness of perinatal depression has been increased (Bilszta, et al., 2011, p. 71).

Study Snapshot: The Abstract
Little is known about the practices of primary care physicians regarding the prescribing of antidepressants during pregnancy.  An anonymous survey was administered to a group of non-randomly selected Australian general practitioners (n=61 out of 77) and randomly selected Canadian family physicians (n=35 out of 111) (Canada…what’s up?).  Responses to a hypothetical scenario and questions regarding beliefs about the use of antidepressant medication during pregnancy were collected. Physicians from both countries feel strongly that antidepressant use during pregnancy is a decision complicated by conflicting reports of safety and risk. (Bilszta, et al. 2011, p. 71)

Care providers make decisions—continue or discontinue medication in pregnancy.  Making this decision is riddled with confusion over conflicting literature, fear of legal liability, and influenced by  patient concern.  Care providers overwhelmingly consider and are influenced by patient concerns in decision making (Canadian FP’s 82.8% vs. 95% of Australian GP’s). Keeping that in mind, take a look at the trends in similarities and differences regarding beliefs and attitudes:

Similarities in attitudes, concerns

  • Perceived levels of misinformation about safety of antidepressant medication in pregnancy: (Australia 74.6% vs. Canada 82.1%)
  • Pregnant depressed women should be treated differently from nonpregnant depressed women (Australia 53.3% vs.  Canada 48.3%)
  • Concerns over legal liability (Australia 55% vs. Canada 55.2%)

Differences in perceptions and confidence

  • Perceived safety of antidepressants for mother during pregnancy (Australia 41.7% vs. Canada 82.8%).
  • Perceived safety of antidepressants for fetus during pregnancy (Australia 10% vs. Canada 48%).
  • Confidence in giving advice about antidepressant use during pregnancy (Australia 33.3% vs. 57.1%).

Are you positive?
The quantitative data regarding benefits and risks of antidepressant use in pregnancy is conflicting.  Bilszta et al., (2011) presented one example of how conflicting data, concern for patient and legal liability, and shaky care guidelines creates a perfect storm for lack of care provider confidence.  Decision making in this atmosphere is difficult at best, injurious at worst.  From a strictly positivist perspective, it is easy to just dig our data-based heels in and proceed to pick apart studies, methods, sample size, statistical significance and eventually talk treatment until we get mad at each other.  But I argue there is something else here—there is potential.   From a post positivist perspective, the issue brought to light by Bilszta et al. (2011), and by Dr. Klein, is the nature of how care providers attitudes manifest (that’s us, too).  In essence, there is as much, if not more, to glean from unpacking the nature data-driven attitudes, as there is from individual data present.

Skeptic Michael Shermer (2011) recently noted:

“Our perceptions about reality are dependent on the beliefs that we hold about it, belief-dependent realism.  Once we form beliefs and make commitments to them, we maintain and reinforce them through a number of powerful cognitive biases that distort our percepts to fit belief concepts.” (Scientific American, July, 2011 p. 85).

Unpacking how attitudes are collectively created, birth advocates included, we will begin to shift the paradigm from “What are they doing or not doing to disadvantage childbearing women?” to “How are WE co-creating this reality and how do we change it”?

Walker’s note: The last author on this study, Adrienne Einarson, has published prolific empirical research on teratogenicity issues of medication in childbearing and breastfeeding women. Hearing her speak was a pivotal moment in my career, and in deconstructing my own paradigms.  I will always be tremendously thankful for that, and for her. Her decades of research at Motherisk merits recognition.  She has devoted her career to pregnant and breastfeeding women, could research circles around the lot of us —and speaks truth to power with humor and tenacity that would make any advocate proud.

Posted by: Walker Karraa, MFA, MA, CD (DONA)

References

Bilszta J. L., Tsuchiya S., Han K., Buist, A. & Einarson, A. (2011). Primary care physician’s attitudes and practices regarding antidepressant use during pregnancy: a survey of two countries.Archive of Womens Mental Health 14, p. 71-75.

Shermer, M. (2011). The believing brain: Why science is the only way out of the trap of belief-dependent realism. Scientific American, July.

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