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Abstract
Objectives Perinatal mental health disorders such as anxiety, depression and bipolar disorder can negatively impact the health of women and their children without appropriate detection and treatment. Due to increases in mental health symptoms and transmission risks associated with in-person appointments, many clinics transitioned to providing telepsychiatry care during the COVID-19 pandemic. This study sought to identify the facilitators and barriers to receiving perinatal telepsychiatry care from the perspective of patients, clinic staff and psychiatrists.
Design Qualitative study based on analysis of in depth semistructured interviews.
Setting The study was conducted in a virtual specialty mental health clinic in an academic setting.
Participants Eight patients who had been scheduled for an appointment with the perinatal telepsychiatry clinic between 14 May 2021 and 1 August 2021, seven of whom had attended their scheduled appointment with the clinic and one of whom had not, and five staff members including psychiatrists, navigators and clinic managers, participated in in-depth interviews.
Results Telepsychiatry was perceived by most as preferable to in-person care and easy to attend and navigate. Alternatively, technological difficulties, personal preference for in-person care and scheduling conflicts related to the perinatal period were identified as barriers by some. Participants identified communication between care staff and patients, online patient portals, and appointment reminders as important for facilitating appointment preparedness and attendance.
Conclusions The findings from this study suggest that telepsychiatry services are perceived positively by patients and care staff and have the potential to improve access to mental healthcare for perinatal patients.
- Mental health
- Pregnancy
- Postpartum
- Telemedicine
- Telepsychiatry
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study used semistructured interview guides based on the patient journey conceptual model.
Blinded qualitative analyses were conducted by two coders on the same interview to ensure consistent coding.
This study had a small sample size of eight patient interviews and five clinic staff interviews, and did not represent patients who did not attend their appointment.
Introduction
Psychiatric conditions that occur during pregnancy and up to 12 months post partum (perinatal mental health disorders (PMHDs)) include anxiety (generalised anxiety disorder, panic disorder, post-traumatic stress disorder and obsessive–compulsive disorder), depression, bipolar disorder and psychosis (postpartum psychosis, schizophrenia and schizoaffective disorder). Depression and anxiety are the most common PMHDs, and are associated with an increased risk of pre-eclampsia, preterm birth, low birth weight and other adverse impacts for the parent and the child.1 There has been an increase in perinatal mental health symptoms since the onset of the COVID-19 pandemic,2 partly due to the effects of social isolation, but also, specifically among pregnant individuals, due to concerns over increased susceptibility to the complications of COVID-19, vertical transmission to the fetus and potential separation from the newborn at birth,3–5 and restrictions on visitors and support individuals during labour and delivery.
Telehealth (phone appointments, synchronous appointments conducted via teleconference—telepsychiatry, text messages and mobile phone applications6) emerged as a useful way to provide psychiatric support to patients while limiting in-person exposure to COVID-19.7 Recent studies on telepsychiatry have demonstrated its positive impact on screening and diagnosis, improved access to treatment and patient engagement, and improved patient outcomes for perinatal behavioural health issues.8 Additionally, as national guidelines recommend that obstetric clinicians screen for perinatal mental health conditions in the context of prenatal care,9 telepsychiatry can provide a more accessible referral pathway for patients with positive screens.
Nevertheless, there are obstacles to implementing telepsychiatry programmes including poor internet connectivity, childcare responsibilities, lack of equipment and lack of privacy,10 11 but obstacles have not been examined in detail since the rapid increase in telepsychiatry in the context of the COVID-19 pandemic.12 Physicians also face challenges in implementing telehealth, such as lack of time, poor technical support and difficulty integrating telehealth into clinical practices11 and there is a need to examine provider level barriers as well. As we consider how much care to provide by telemedicine after the end of the pandemic, it is important to understand barriers and facilitators to perinatal telepsychiatry from the perspective of patients, clinic staff and psychiatrists. The current quality improvement project aimed to explore these factors in a perinatal telepsychiatry service launched in response to the pandemic.
Methods
Study design and clinic setting
This was a qualitative study based on analysis of in depth semistructured interviews.
In the spring of 2020, we launched a new perinatal telepsychiatry clinic in response to increases in perinatal mental health symptoms related to the COVID-19 pandemic. The clinic offers virtual psychiatric consultations for perinatal mental health and/or substance use concerns. We aimed to address barriers to perinatal mental health access by focusing our outreach efforts on counties with fewer perinatal mental health providers and higher number of births. We also conducted targeted outreach to home visiting and public health programmes that serve clients with psychosocial risk factors. The patient’s referring provider (eg, obstetric provider, primary care provider, social worker, public health nurse) completes a REDCap13 intake survey referral. Then, clinic navigators call patients and schedule them for an appointment with a perinatal psychiatrist. After the appointment, the psychiatrist contacts the referring provider with treatment recommendations. Clinic staff includes navigators and programme administrators who provide supervision to navigators and manage continuous quality improvement efforts.
Study eligibility, recruitment and procedures
Study participants included patients and clinic staff. Patients who were eligible to participate in the study were English-speaking and had been scheduled for an appointment (including those who attended and did not attend their appointment) with the perinatal telepsychiatry clinic between 14 May 2021 and 1 August 2021 (the quality improvement project period). Among eligible patients, we planned to reach out to six patients who did and six patients who did not attend their scheduled appointment. We based this total number on recommendations for a sample size of 5–10 interviews in similar studies.14 15 The study team reached out to each of 53 eligible participants at least three times, once each by email, text and phone call until they made contact. A total of five clinic staff (two psychiatrists, one mental health navigator, one navigator supervisor and one expert in telepsychiatry) were invited to participate in interviews and all of the individuals invited to participate were interviewed. We developed semistructured interview guides (online supplemental appendix 1) based on the patient centred journey map conceptual model,16 with separate guides for patients who attended and did not attend their appointment, and for clinic staff and consulting psychiatrists. We tailored questions to each participant’s unique experiences or roles before, during and after the appointment. We obtained informed consent from all participants prior to interviews. Phone interviews lasting 30–45 min were conducted one on one with each participant by AH, SW and AY, female identifying public health students who introduced their role to the participant before beginning the interview. Each interview was recorded and transcribed using Otter.io software for analysis. No repeat interviews were conducted. Patients were compensated for their time with US$25 gift cards.
Supplemental material
Analysis
Researchers used the software ‘Dedoose’ to code interview transcripts and conduct thematic analysis17 using a deductive approach. We based codes on interview questions and focused on the differences in perspectives of patients and clinic staff, adding codes as new topics of interest arose during analysis. Each researcher independently coded one patient interview and one clinic staff interview, then codes were compared between coders to resolve discrepancies. and ensure agreement on code definitions between all researchers. We recorded all codes and descriptions in a codebook which we iteratively modified throughout the analysis process based on consensus. We used transcriptions as data and applied thematic analysis to all the transcripts.18 19 We coded 13 patient and clinic staff transcripts, with at least 2 researchers coding each transcript, resolving discrepancies by consensus. AH and SW coded four patient transcripts and three clinic staff transcripts, while AY coded six patient transcripts and two clinic staff transcripts. We were able to achieve thematic saturation by the end of the coding process, that is, further analysis and discussion did not reveal any more new codes.20
Patient and public involvement
None.
Results
Participants
We reached out to 53 patients and 8 patients agreed to participate (7 who attended their perinatal telepsychiatry appointment and 1 who had an appointment scheduled but did not attend the appointment—a 15% response rate). All patients identified as female. Based on information provided by referring provider in the intake form three referring providers noted that their patients identified as white or European American, one was African American and four were not noted. Patients interviewed resided in six counties geographically dispersed within the state.
Five staff members were interviewed, including two psychiatrists, one navigator and two administrators chosen using convenience sampling.
Themes
Themes identified in patient, staff and psychiatrist interviews are described below and in table 1.
Themes and quotes from patient, psychiatrist and staff interviews
Advantages to telepsychiatry
The convenience of attending a remote appointment eliminated the need for transportation to and from an in-person appointment, leading to saved time and energy and improved mental healthcare access overall. One patient stated, ‘I’m more likely to actually make an appointment to see somebody [if] I know that I don’t have to actually plan my day around leaving.’ Another patient expressed, ‘…knowing that you don’t have to travel…and that all you have to do is turn your computer on and talk to someone, I found to be really helpful.’
Cost savings were another significant advantage of telepsychiatry from the patient perspective. Reduced financial costs of transportation and childcare were commonly mentioned by patients. One patient shared, ‘Honestly, I probably would opt for the virtual care, just because I mean, gas prices are going up. And a lot of the time these appointments are pretty far away from where I'm living’.
Accessing telepsychiatry appointments from home was a source of comfort for patients. Many patients were caring for children and family while working from home during the COVID-19 pandemic. One patient said, ‘I have a toddler and my husband works in a hospital. So, he has really weird hours….so not having to get childcare is another helpful thing.’ Some patients experienced anxiety and discomfort with driving and felt that online appointments helped reduce stress.‘…I had a lot of anxiety like driving…I probably wouldn’t have been seen if I couldn’t have done it [via] telehealth.’ Others expressed anxiety over meeting people in person, and thus preferred virtual care to relieve the social anxiety of meeting in person. ‘I have social anxiety, I get nervous about meeting new people….the drive into the office and finding a parking spot, or like just getting to know a new facility adds to the anxiety…And so eliminating the driving and new surroundings…just makes it easier for me to more quickly settle into being my natural self with a new provider who I haven’t met before.’ Importantly, pregnant and postpartum patients also valued the safety of attending appointments at home without exposing themselves or family members to COVID-19.
Barriers to telepsychiatry
Technical difficulties and hesitations around using unfamiliar technology were identified as barriers to attending and completing telepsychiatry appointments. For example, one member of the clinic staff stated that ‘it can also be a barrier to access the people who aren't comfortable using the technology or don't have access to a device or enough minutes on their phone or, you know, good broadband or something like that.’
Some patients observed decreased connection and rapport with providers during telepsychiatry appointments as opposed to in person appointments. A patient reported ‘I think there’s, like a lot more comfort and sort of reassurance that can come when you're in person’ and a provider added that rapport building ‘can be a little bit slower when you're meeting someone virtually.’
Virtual care was also considered a potential limitation by patients and psychiatrists when physical examination or lab tests were needed. When asked if they would prefer a virtual care visit to one in person, a patient responded that they would only if they ‘don't need something to be physically looked at or [have] blood taken or anything like that.’
Barriers specific to the perinatal experience were also identified as many patients were experiencing stressful life events that made it more difficult to attend their appointment, even from home. Expressing the difficulties of attending their appointment, one patient told the interviewer, ‘I actually have rescheduled this appointment, about, I don't know, … like four or five times, because … I've been going through a lot of, a lot of crazy stuff that I've never dealt with my life.’
The importance of communication between care staff and patients
Communication played a critical role in facilitating appointment attendance. Psychiatrists and clinic staff identified a need to clearly communicate that the service was a consultation service. Patients felt more mentally prepared for the appointment if they were aware ahead of time what to expect and the type of care and conversations they would experience. One patient said, ‘I wish I would have known just a little bit more before,…I would have been mentally more prepared to know what to expect knowing that it would just be like, a one-time thing with a provider who would like … evaluate me’ Having open lines of communication with the clinic was also noted to be a significant relief for patients to ask questions or confirm details about the appointment. A patient explained, ‘… or they'll call you, I really appreciated that the clinic called me. And I always, you know, that was really convenient. Having like, a way to text message was also really, like, you use text message to like follow-up on the email, I think that was really good as well.’
An area for improvement in communication noted was between referring provider and patient. Patients and clinic staff noted that when the referring provider did not discuss the need for a perinatal psychiatry appointment with their patient, this could be a barrier to appointment completion and scheduling.
The use of technology to facilitate appointment attendance
Most interviewed patients had positive things to say about using technology to set up their appointment, ask clarifying questions or attend their appointment. Patients had used the Zoom platform previously during the COVID-19 pandemic. Additionally, patients mentioned the ease of using electronic medical record messaging to help them access their information in one central location. Another noted the ease of using their phone, explaining ‘…all this stuff that you normally do for an appointment I was able to do on my phone. So it was like, easier than having to go in and fill out paperwork.’
Suggestions to improve telepsychiatry
Patients noted that creating additional time slots on evenings and weekends to improve accessibility and reminders about the appointment date and time through email and text message would lead to improved attendance. Receiving a ‘preappointment orientation’ in the form of a virtual meeting or phone call with clinic staff would also increase patient engagement by providing opportunities to discuss questions or concerns about telepsychiatry. Setting expectations about the nature of the psychiatric referral and the purpose of the appointment would ease uncertainty during the telepsychiatry appointment.
Telepsychiatry beyond the COVID-19 pandemic
Patients differed in their position on choosing telepsychiatry vs in person care in the absence of a pandemic and clinic closures. One patient stated that that ‘if the pandemic were never a thing, I would have never thought to do virtual therapy, … But now that ….I have experienced virtual, I would choose virtual.’ Others felt that after the pandemic, virtual care would only be acceptable in certain situations. One patient stated, ‘I think I would still choose virtual care, I guess, depending on like, where the clinic was located… just kind of not have to do that commute,’ suggesting that if the clinic was closer, she would be more likely to attend an in-person appointment. Another patient added that ‘it depends on the service… there are some things that I like to go in person for my PCP,’ suggesting that the acceptability of telemedicine may differ by specialty. This was reflected in a staff statement ‘Oh, I think it’s here to stay, especially in behavioral health. …the uptake of telemedicine services for behavioural health, medical specialties, surgical specialties, … after a few months, and the pandemic seemed to be easing, things drop down quite a bit for the other three specialties, but the behavioral health stayed at 72%.’
Discussion
Previous studies include those that have focused on postpartum depression outcomes in telepsychiatry programmes,21 survey-based studies of telehealth for perinatal psychiatry,22 and barriers to accessing perinatal mental health treatments.23 To our knowledge, this is the first study including in depth interviews with patients and clinic personnel, conducted after telepsychiatry became more widely used in the context of the COVID-19 pandemic. In contrast to patient experiences around virtual or telehealth visits for obstetric care,24 wherein most patients preferred in person visits and felt that virtual care was inadequate to meet their needs, we found that telepsychiatry was highly acceptable to perinatal patients.
This study defined several barriers and facilitators experienced by patients, clinic staff and care providers from a perinatal telepsychiatry clinic established in response to the COVID-19 pandemic. Clinic staff discussed potential barriers to accessing telepsychiatry more frequently than patients did such as challenges with technology, building rapport, lack of childcare and challenges providing high-quality healthcare. Although patients did discuss similar disadvantages to telepsychiatry, they discussed the advantages of accessing and using telepsychiatry more frequently than they discussed barriers. Patients appreciated the flexibility of attending appointments from home, specifically in the perinatal period, saving time and money by not commuting, and avoiding the anxiety caused by travelling to a new environment and meeting new people.
Our sample size was small with a low response rate of 15% despite several outreach attempts, and our findings may not capture the diversity of perspectives. This quality improvement project aimed to obtain information to improve the quality of the clinical service being provided by exploring barriers and facilitators to perinatal telepsychiatry. As such, it would have been valuable to have a larger sample size. In addition, a significant limitation of this study is that we could not include patients who did not attend their appointment . The perspectives of non-attendees, who presumably experienced more barriers than those who did attend, would have enriched the qualitative data. Although our sample size was theoretically adequate for saturation, it was not representative because of the low number of participants who did not attend their appointment. However, interviews with clinic staff provided some insight into potential barriers that non-attendees may have faced. Clinic staff mentioned possible lack of privacy at home for telepsychiatry, and that since there was no need to leave and travel somewhere for a telehealth appointment, it may be easier for people to forget, or for something to come up unexpectedly, especially for people with young children in the home. Given the limited scope of this quality improvement project, we could not conduct member checking of our results. However, member or participant checking has limited utility in qualitative studies such as the present one, which are not designed as participatory projects.25
Patients reported that they would like more information about the format of the appointment before they attended it. Clinic staff highlighted the importance of ensuring that patients have resources after their telepsychiatry visits. Additionally, clinic staff noted that improved communication between patients and their referring provider led to more specific treatment and better quality of care beyond the telepsychiatry appointment itself. These suggestions are generalisable and can be used as facilitators to appointment completion in the future and adapted to the needs of other telehealth clinics to deliver the highest quality of care and provide patients with ongoing support. With regard to perinatal mental health, given the additive stigma of mental health and fear of being judged an inadequate parent, non-judgemental and compassionate support, providing information to patients and closely involving the patient in treatment decisions, and providing individualised treatment, are critically important26 and must be included in telepsychiatric care for perinatal patients as well.
Conclusion
The current findings show that telepsychiatry improves access to perinatal mental health and substance use care especially during COVID-19, and that perinatal patients have a positive experience with using telepsychiatry services. Preliminary investigations have found perinatal telepsychiatry to be feasible for inpatient consults to obstetrics.27 Future research should investigate facilitators and barriers to telepsychiatry specific to rural populations, patients whose primary language is not English, and patients who were not able to complete their appointments. These groups are disproportionately impacted by perinatal mental health and substance use care as well as COVID-19, due to low resource access and language barriers.28 Some of our participants preferred telepsychiatry due to their anxiety about driving to their appointments or about in person interactions. There is a need to examine whether telepsychiatry can inadvertently worsen these anxieties by perpetuating avoidance, or whether initial telepsychiatry appointments can help build rapport with the provider and encourage in person attendance. The waivers of regulatory requirements around telehealth service delivery that have been in place since the onset of the COVID-19 pandemic are an obvious facilitator of these services29 that we did not examine in this study but are important to keep in mind as we continue to offer telehealth services beyond the pandemic.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study was considered a quality improvement project and was determined to be exempt from review by the institutional review board.
Acknowledgments
We would like to acknowledge the individuals that participated in this project including all the patients, psychiatrists, navigators and administrators who participated in the interviews. We thank Deborah Cowley, MD for her comments on the manuscript and Theresa Hoeft, PhD for her input on the qualitative analysis.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
AH and SW are joint first authors.
Contributors AB and JA conceived of the project and developed the theory. AH, SW and AY developed the interview guides and conducted the interviews. AH, SW and AY developed the codebook and performed coding and analysis. AB verified the analytical methods. AB accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish. All authors discussed the results and contributed to the final manuscript.
Funding This work was supported by The Perigee Fund (grant number N/A).
Disclaimer The funder had no involvement in study design; collection, analysis and interpretation of data; writing of the report; or in the decision to submit the article for publication.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.