A qualitative study into how guidelines facilitate general practitioners to empower women to make decisions regarding antidepressant use in pregnancy

Research output: Contribution to journalArticlepeer-review


It is estimated that 14.5%of women suffer depression in pregnancy [Sit,D.K.Y., Flint, C.,Svidergol, D., White, J., Wimer, M., Bish, B., & Wisner, K.L. (2009). An emerging bestpractice model for perinatal depression care. Psychiatric Services, 60, 1429–1431.Retrieved from http://ps.psychiatryonline.org/journal.aspx?journalid¼18], which hasbeen linked to a number of negative outcomes such as higher levels of preterm delivery,reduced cognitive development and poor mother–baby connection [Judd, F., Stafford, L.,Gibson, P., & Ahrens, J. (2011). The early motherhood service: An acceptable andaccessible perinatal mental health service. Australasian Psychiatry, 19, 240–246.doi:10.3109/10398562.2011.562294]. The lack of clarity surrounding safety informationhas impacted treatment decisions with general practitioners (GPs) reportedly feelinghesitant to prescribe antidepressants [Bilszta, J.L., Tsuchiya, S., Han, K., Buist, A.E., &Einarson, A. (2011). Primary care physicians attitudes and practices regardingantidepressant use during pregnancy: A survey of two countries. Archive of Women’sMental Health, 14, 71–75. doi:10.1007/s00737-010-0197-8], yet the usage of perinataldepression guidelines among GPs is reportedly low [Kean, L.J., Hamilton, J., & Shah, P.(2011). Antidepressants for mothers:What are we prescribing? Scottish Medical Journal,56, 94–97. doi:10.1258/smj.2011.011034]. Therefore, this study aimed to explore theopinions of GPs on how clinical guidelines for perinatal depression facilitated them toempower pregnant women to make an informed decision about the use of antidepressantsin pregnancy. Using qualitative methodology, semi-structured interviews were conductedwith one GP from eight practices in Derry City, Northern Ireland. The main areasexplored in the interview schedule were guidelines on perinatal depression, GPunderstanding of ‘patient empowerment’, GP practice policy on patient decision making,constraints of treatment decisions and a discussion on which health promotion model wasmost reflective of their views on the provision of healthcare. Only some of the GPs wereaware of the National Institute National Institute for Health and Clinical ExcellenceClinical Excellence [NICE (2007). Antenatal and postnatal mental health: Clinicalmanagement and service guidance (Clinical Guideline No. CG45). Retrieved from http://www.nice.org.uk/nicemedia/live/11004/30433/30433.pdf] perinatal depression guidelinesbut acknowledged that they were generic and lacked utility, instead they relied ontheir own professional experience and patient knowledge to make decisions. Involvingpatients in treatment decision making was viewed as central to patient empowerment;however, its application in routine practice was often limited by complex clinicalscenarios. Findings from this study suggested an identified need for a local specialistperinatal service to provide evidence-based information and timely support. Anempowerment model for the improvement of perinatal depression has been developed from the study findings as a framework for women, their community and their GPs.
Original languageEnglish
JournalInternational Journal of Mental Health Promotion
Volume25 Mar
Publication statusPublished - 25 Mar 2013

Bibliographical note

Reference text: Adams, J.R., & Drake, R.E. (2006). Shared decision making and evidence-based practice.
Community Mental Health Journal, 42(1), 87–105. doi:10.1007/s10597-005-9005-8.
Anderson, R.M., & Funnell, M.A. (2010). Patient empowerment: Myths and misconceptions. Patient Education and Counseling, 79, 277–282. doi:10.1016/i.pec.2009.07.025.
Aujoulat, I., d’Hoore, W., & Deccache, A. (2007). Patient empowerment in theory and practice: Polysemy or cacophony. Patient Education and Counseling, 66, 13–20. doi:10.1016/j.pec.2006.09.008.
Avis, M. (2005). Is there an epistemology for qualitative research? In I. Holloway (Ed.), Qualitativeresearch in health care (pp. 3–15). Maidenhead: Open University Press.
Bennett, I.M., Marcus, S.C., Palmer, S.C., & Coyne, J.C. (2010). Pregnancy-related discontinuationof antidepressants and depression care visits among Medicaid recipients. Psychiatric Services,61, 386–391. Retrieved from http://ps.psychiatryonline.org/journal.aspx?journalid=18
Bermejo, I., Schneider, F., Kriston, L., Gaebel, W., Hegrel, U., Berger, M., & Harter, M. (2009).
Improving outpatient care of depression by implementing practice guidelines: A controlled
clinical trial. International Journal for Quality in Health Care, 21(1), 29–36.
Bilszta, J., Ericksen, J., Buist, A., & Milgrom, J. (2010a). A qualitative study of health professionals involved in the care and treatment of woman with postnatal emotional distress. International Journal of Mental Health Promotion, 12(3), 5–13. Retrieved from http://www.ijmhp.co.uk/
Bilszta, J., Ericksen, J., Buist, A., & Milgrom, J. (2010b). Women’s experience of postnatal
depression-beliefs and attitudes as barriers to care. Australian Journal of Advanced Nursing,27(3), 44–54. Retrieved from http://www.ajan.com.au/
Bilszta, J.L., Tsuchiya, S., Han, K., Buist, A.E., & Einarson, A. (2011). Primary care physician’sattitudes and practices regarding antidepressant use during pregnancy: A survey of two countries. Archive of Women’s Mental Health, 14, 71–75. doi:10.1007/s00737-010-0197-8.
Bonari, L., Koren, G., Einarson, T.R., Jasper, J.D., Taddio, A., & Einarson, A. (2005). Use of
antidepressants by pregnant women: Evaluation of perception of risk, efficacy of evidence based counselling and determinants of decision making. Archives of Women’s Mental Health, 8,214–220. doi:10.1007/s00737-005-0094-8.
Buist, A., Bilszta, J., Barnett, B., Milgrom, J., Ericksen, J., Condon, J., . . . , & Brooks, J. (2005).
Recognition and management of perinatal depression in general practice. Australian Family Practice, 34(9), 787–790. Retrieved from http://www.racgp.org.au/afpbackissues/2005/200509/200509buist.pdf
Buist, A., Bilszta, J., Milgrom, J., Barnett, B., Hayes, B., & Austin, M.P. (2006). Health
professional’s knowledge and awareness of perinatal depression: Results of a national survey. Women and Birth, 19, 11–16. doi:10.1016/j.womi.2005.12.001.
Clever, S.L., Ford, D.E., Rubenstein, L.V., Rost, K.M., Meredith, L.S., Sherbourne, C.D., . . ., &
Cooper, L.A. (2006). Primary care patients’ involvement in decision-making is associated with improvement in depression. Medical Care, 44(5), 398–405. Retrieved from http://journals.lww.com/lww-medicalcare/pages/default.aspx
Cohen, L.S., Nonacs, R.M., & Bailey, J.W. (2004). Relapse of depression during pregnancy
following antidepressant discontinuation: A preliminary prospective study. Archive Women’s
Mental Health, 7, 217–221. doi:10.1007/s00737-004-0059-3.
Colaizzi, P. (1978). Psychological research as the phenomenologist views it. In R. Vale and M. King, (eds). Existential phenomenological alternatives for psychology (48–71) New York: Oxford University Press.
Department of Health, Social Services and Public Safety (2003). Investing for health: Promoting mental health strategy and action plan 2003–2008, (Report Reference No. 19/02). Retrieved from http://www.dhsspsni.gov.uk/promoting_mental_health.pdf
Department of Health, Social Services and Public Safety. (2011). Health survey Northern Ireland: First results from the 2010/2011 survey. Retrieved from http://www.dhsspsni.gov.uk/health_
Downie, R.S., Tannahill, C., & Tannahill, A. (1996). Health promotion: Models and values. Oxford:Oxford Medical Publications.
Fishbein, M. (2008). A reasoned action approach to health promotion. Medical Decision Making, 28(6), 834–844. doi:10.1177/0272989x08326092.
Fisher, P., & Owen, J. (2008). Empowering interventions in health and social care: Recognition through ‘ecologies of practice’. Social Science and Medicine, 67, 2063–2071. doi:10.1016/j.socscimed.2008.09.035.
Gentile, S., & Galbally, M. (2011). Prenatal exposure to antidepressant medications and
neurodevelopmental outcomes: A systematic review. Journal of Affective Disorders, 128(1–2),1–9. doi:10.1016/j.jad.2010.02.125.
Goodman, J.H. (2009). Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth, 36(1), 60–69. Retrieved from http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1523-536X
Holzman, C., Eyster, J., Tiedje, L.B., Roman, L.A., Seagull, E., & Rahbar, M.H. (2006). A life
course perspective on depressive symptoms in mid-pregnancy. Maternal and Child Health
Journal, 10(2), 127–138. doi:10.1007/s10995-005-0044-0.
Judd, F., Stafford, L., Gibson, P., & Ahrens, J. (2011). The early motherhood service: An acceptable and accessible perinatal mental health service. Australasian Psychiatry, 19(3), 240–246. doi:10.3109/10398562.2011.562294.
Kean, L.J., Hamilton, J., & Shah, P. (2011). Antidepressants for mothers: What are we prescribing? Scottish Medical Journal, 56, 94–97. doi:10.1258/smj.2011.011034.
Laverack, G. (2005). Public health: Power, empowerment and professional practice. Hampshire:Palgrave Macmillan.
Lee, A.M., Lam, S.K., Sze Mun Lau, S.M., Shin Yin Chong, C., Wai Chui, H., & Yee Tak Fong, D.(2007). Prevalence, course and risk factors for antenatal anxiety and depression. Obstetrics and Gynecology, 110(5), 1102–1112. doi:10.1097/01.AOG.0000287065.59491.70.
Lewis, A.J., Galbally, M., Opie, G., & Buist, A. (2010). Neonatal growth outcomes at birth and one month postpartum following in utero exposure to antidepressant medication. Australian and New Zealand Journal of Psychiatry, 44, 482–487. Retrieved from http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1440-1614
Loureiro, M.I., Goes, A.R., Da Camara, G.P., Goncalves-Pereira, M., Maia, T., & Nunes, L.S.
(2009). Priorities for mental health promotion during pregnancy and infancy in primary health care. Global Health Promotion, 16(1), 29–38. doi:10.1177/1757975908100748.
Marcus, S.M., & Flynn, H.A. (2008). Depression, antidepressant medication, and functioning
outcomes among pregnant women. International Journal of Gynecology and Obstetrics, 100(3),248–251. doi:10.1016/ijgo.2007.09.016.
McConnell, P., Bebbington, P., McClelland, R., Gillespie, K., & Houghton, S. (2002). Prevalence of psychiatric disorder and the need for psychiatric care in Northern Ireland: Population study in the District of Derry. The British Journal of Psychiatry, 181, 214–219. doi:10.1192/bjp.181.3.214.
Mcdaid, S., & Delaney, S. (2011). A social approach to decision-making capacity: Exploratory
research with people with experience of mental health treatment. Disability and Society, 26(6),729–742. doi:10.1080/09687599.2011.602864.
Murphy, H., & Lloyd, K. (2007). Civil conflict in Northern Ireland and the prevalence of psychiatric disturbances across the United Kingdom: A population study using the British Household Panel survey and the Northern Ireland Household panel survey. International Journal of Social Psychiatry, 53(5), 397–407. doi:10.1177/0020764007078340.
Naidoo, J., & Willis, J. (2009). Foundations for health promotion. London: Bailliere Tindall
Nakhai-Pour, H.R., Broy, P., & Berard, A. (2010). Use of antidepressants during pregnancy and the risk of spontaneous abortion. Canadian Medical Association Journal, 182(10), 1031–1037. doi:10.1503/cmaj.091208.
National Institute for Health and Clinical Excellence. (2007). Antenatal and postnatal mental health: Clinical management and service guidance (Clinical Guideline No. CG45). Retrieved from http://www.nice.org.uk/nicemedia/live/11004/30433/30433.pdf
Nekui, N.S., Kazemi, A., & Emami, S.D. (2007). Preconceptional care for diabetes: Health care provider’s experiences on how the patients face disease and pregnancy. Iranian Journal of Nursing and Midwifery Research, 12(4), 115–119. Retrieved from http://www.ijnmr.mui.ac.ir/index.php/ijnmr
Northern Ireland Statistics and Research Agency (2010). Using the Northern Ireland multiple deprivation measure, (Research Report No. Unavailable). Retrieved from http://www.nisra.gov.uk/deprivation/archive/Updateof2005Measures/NIMDM_2010_Guidance_Leaflet.pdf
Oates, M. (2003). Perinatal psychiatric disorders: A leading cause of maternal morbidity and
mortality. British Medical Bulletin, 67, 219–229. doi:10.1093/bmb/ldg011.
Oberlander, T.F., Gingrich, J.A., & Ansorge, M.S. (2009). Sustained neurobehavioural effects of exposure to SSRI antidepressants during development: Molecular to clinical evidence. Clinical Pharmacology and Therapeutics, 86(6), 672–677. doi:10.1038/clpt.2009.20.
O’Reilly, D., & Stevenson, M. (2003). Mental health in Northern Ireland: Have ‘the troubles’ made it worse? Journal of Epidemiology and Community Health, 57, 488–492. Retrieved from http://jech.bmj.com/
Parahoo, K. (2006). Nursing research: Principles, process and issues. Basingstoke: Palgrave Macmillan.
Ramos, E., Oraichi, D., Rey, E., Blais, L., & Berard, A. (2007). Prevalence and predictors of
antidepressant use in a cohort of pregnant women. An International Journal of Obstetrics andGynaecology, 114(9), 1055–1064. doi:10.1111/j.1471-0528.2007.01387.x.
Ramos, E., St-Andre, M., & Berard, A. (2010). Association between antidepressant use during pregnancy and infants born small for gestational age. The Canadian Journal of Psychiatry, 55(10), 643–652. Retrieved from http://publications.cpa apc.org/browse/sections/0
Salmon, P., & Hall, G.M. (2004). Patient empowerment or the emperor’s new clothes. Journal of the Royal Society of Medicine, 97, 53–56. Retrieved from http://jrsm.rsmjournals.com/
Say, R., Murtagh, M., & Thomson, R. (2006). Patients’ preference for involvement in medical
decisional making: A narrative review. Patient Education and Counseling, 60, 102–114.
Retrieved from http://www.pec-journal.com/
Sit, D.K.Y., Flint, C., Svidergol, D., White, J., Wimer, M., Bish, B., & Wisner, K.L. (2009). An
emerging best practice model for perinatal depression care. Psychiatric Services, 60(11),
1429–1431. Retrieved from http://ps.psychiatryonline.org/journal.aspx?journalid=18
Stacey, D., Menard, P., Gaboury, I., Jacobsen, M., Sharif, F., Ritchie, L., & Bunn, H. (2008).
Decision making needs of patients with depression: A descriptive study. Journal of Psychiatric and Mental Health Nursing, 15, 287–295. Retrieved from http://onlinelibrary.wiley.com/ journal/10.1111/(ISSN)1365-2850/
Tones, K., & Tilford, S. (2001). Health promotion: Effectiveness, efficiency and equity. Cheltenham: Nelson Thornes.
Wisner, K., Zarin, D.A., Holmboe, E.S., Appelbaum, P.S., Gelenberg, A.J., Leonard, H.L., & Frank, E. (2000). Risk-benefit decision making for treatment of depression during pregnancy. American Journal of Psychiatry, 157(12), 1933–1940. doi:10.1176/appi.ajp.157.12.1933.
World Health Organisation. (1997). The Jakarta declaration on leading health promotion into the 21st century, (Research Report No. Unavailable). Retrieved from http://www.who.int/
World Health Organisation. (2009). Women and health: Today’s evidence tomorrow’s agenda (NLM classification: WA 309). Retrieved from http://whqlibdoc.who.int/publications/2009/9789241563857_eng.pdf
World Health Organisation. (2011). Impact of economic crisis on mental health (Research Report No. Unavailable). Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf
World Health Organisation. (2012). Mental health: What is depression? (Research Report No.Unavailable). Retrieved from http://www.who.int/mental_health/management/depression/
Yonkers, K.A., Wisner, K.L., Stewart, D.E., Oberlander, T.F., Dell, D.L., Stotland, N., . . ., &
Lockwood, C. (2009). The management of depression during pregnancy: A report from the
American Psychiatric Association and the American College of Obstetricians and Gynaecologists. General Hospital Psychiatry, 31, 403–413. doi:10.1016/j.genhosppsych.2009.04.003.


  • perinatal depression
  • guidelines
  • general practitioners
  • empowerment
  • qualitative


Dive into the research topics of 'A qualitative study into how guidelines facilitate general practitioners to empower women to make decisions regarding antidepressant use in pregnancy'. Together they form a unique fingerprint.

Cite this