Table 1 Studies included in qualitative synthesis

Bilszta et al. [15]

Explore primary health care physician’s beliefs and practices toward perinatal depression by investigating knowledge, attitudes, and practices affecting a physician’s decision to continue or discontinue antidepressant medication during pregnancy.

Quantitative: Survey

Australia and Canada

61 GPs;

33 Family Physicians

Age, years in practice, gender, or personal experiences with depression did not lead to a significant difference in treatment choice.

Prescribing is a third line choice, after counselling or partner support.

Physicians appeared more likely to taper medication in pregnant women, although this is linked to a six-fold increase in risk of relapse for women, indicating an incongruency between risk concerns and potential outcomes of medication management.

Brygger Venø et al. [28]

To explore GP’s perceived indicators of vulnerability among pregnant women in primary care.

Qualitative: Semi-structured focus groups

Southern Denmark

20 GPs

Patient doctor relationship is integral when deciding to ask further questions regarding mental health. GPs were aware of indicators of vulnerability to severe mental health but also referred to a gut feeling when picking up on intangible indicators.

Buist et al. [16]

To identify ways to improve detection of postnatal depression and access to treatment.

Quantitative: Survey vignette

Australia

246 GPs;

525 women

A difference between GP and patient preferences may lead to a hesitancy for women to bring up difficulties if they do not want to be prescribed medication.

The length of time needed for a consult period when identifying postnatal depression is a significant time investment.

Routine enquiry about women’s mood and coping is needed to identify women who might otherwise go undiagnosed.

Chew-Graham et al. [17]

To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression.

Quantitative: Survey within a multicentre RCT

Various locations United Kingdom

19 GPs;

14 Health Visitors

GPs stress the importance of knowing the patient and using a psychosocial approach to making a diagnosis. GPs and Health Visitors agree that diagnosis of postnatal depression is important for management, but the ‘role’ of responsibility on detecting symptoms was unclear.

Chew-Graham et al. [18]

Exploration of views and attitudes of women and GPs following a disclosure of postnatal depression.

Qualitative: In-depth interviews within a multicentre RCT

Various locations United Kingdom

19 GPs;

14 Health Visitors;

28 Women

Psychosocial factors need to be addressed to diagnose and treat postnatal depression.

Diagnoses, or pursuing a diagnosis, are avoided when health care providers feel they have nothing to offer e.g., continuity of care, referral to services. Questioning why a diagnosis of depression is not made by the healthcare professional, and suggesting training to address this issue, is too narrow an approach. Instead, a whole system approach is necessary to improve willingness to disclose, practitioner ability to listen and intervene, and a system that will facilitate management.

Edge [19]

To investigate health professionals’ views about perinatal mental healthcare for Black and minority ethnic women.

Qualitative: Interviews and Focus Groups

United Kingdom (Northern England)

42 health professionals (5 of which were GPs)

Physical health is often prioritised in the postnatal period, mental health can be overlooked.

Services which limit continuity of care, health professional resistance to using psychometric tools, and lack of confidence in managing depression contribute to missed opportunities to detect and treat postnatal depression.

Glasser et al. [20]

To explore Israeli primary care physicians’ attitudes and practice regarding postpartum depression (PPD).

Quantitative: Three question survey

Israel

122 Paediatricians;

102 Family Practitioners

Most of the participants reported that it was important to recognize signs of postnatal depression and to act upon them. This resulted in most respondents reporting they would refer patients onward to mental health professionals.

Significantly more family practitioners would screen for postnatal depression when compared to paediatricians.

Kean et al. [21]

To investigate current prescribing practices among GPs of antidepressants to women presenting in the first trimester of pregnancy and during breastfeeding.

Qualitative: Postal survey vignettes

United Kingdom (Scotland)

32 GPs

When given a list of potential medications to prescribe either in the first trimester, or during breastfeeding, GP prescribing patterns were inconsistent. Knowledge regarding classes of drugs was better than specific drugs within that class. Several GPs still had resistance to using medication for mothers with depression.

There was also limited forward planning with prescribing medication that could be continued through until breastfeeding.

Khan [27]

Understand the role of GPs, and women’s experiences, in disclosure, identification and support with perinatal mental health

Mixed method: surveys and semi-structured interviews

United Kingdom (majority)

43 GPs for the survey;

3 GPs for the interview

Government action is needed to reduce the pressure on GPs and allow for longer consultations periods with women experiencing perinatal mental health problems.

Higher education should work with RCGP Clinical Champion to support specific perinatal mental health training for qualified GPs.

Local education and training boards should develop curriculum competencies relating to perinatal mental health through their GP training programmes.

Evidence should be explored to assess the most effective way to use the six-week check to support mothers, babies, and families.

McCauley & Casson [22]

To develop an in-depth understanding of GPs’ experience of using guidelines in the treatment of perinatal depression and if this enabled them to empower women to become involved in treatment decisions.

Qualitative: Semi-structured interviews

United Kingdom (Northern Ireland)

8 GPs

The purpose of clinical guidelines is to enable GPs to empower women to make informed treatment decisions regarding pregnancy, however, the perceived usage of these guidelines is limited.

GPs felt overwhelmed by too many guidelines, and conflicting safety data.

GPs agree that involving women in the decision-making process is central to their empowerment, but this can be limited by the complexity of the presentation and to what level women want to be involved.

Mortimer et al. [29]

Investigate GPs’ and psychiatrists’ perceptions and experiences of caring for women with PTSD in the postnatal period.

Qualitative: Fictional case vignette

United Kingdom

6 GPs;

7 Psychiatrists

GPs can avoid diagnosis or attribute difficulties to other changes, often taking on a watchful waiting approach.

Birth often isn’t considered a traumatic event by health care professionals, which potentially contributes to the way diagnoses are approached.

Most training regarding postpartum diagnoses focuses on depression and psychosis, leading to a lack of training in other postpartum disorders such as post-traumatic stress disorder (PTSD).

Noonan et al. [30]

To explore GPs’ experiences of caring

for women with perinatal mental health problems and their views on how best

to prepare future GPs for a role in the provision of effective

PMH care.

Qualitative: In-depth semi-structured interviews

Ireland

10 GPs

GPs described their multifaceted role in supporting women with perinatal mental health. GPs identified stigma, cultural and linguistic barriers to disclosure and care. Specialised care when indicated for women is limited due to under resourcing and long wait times.

Training in perinatal mental health is needed, with some GPs suggesting a compulsory psychiatric rotation during training programs. Other options include e-modules to help build GP confidence and knowledge.

Santos Jr et al. [23]

To explore experiences of Brazilian physicians and nurses caring for women with postpartum depression in primary healthcare settings.

Qualitative: Open ended interviews

Brazil

10 nurses;

7 family health physicians

There appeared to be limited exposure to postpartum depression, which in turn created gaps in knowledge about postpartum depression, including its presentation and treatment. Limited clinical knowledge effects screening of postpartum depression and the documentation of symptoms.

Gaps in GP training are highlighted as a potential causal factor for these issues.

Seehusen et al. [24]

To determine how frequently family physicians screen for PPD, what methods they use to screen, and what influences their screening frequency.

Quantitative: 25-item questionnaire

USA (Washington)

298 physicians

Screening for postpartum depression is not universal. When physicians do report screening for postpartum depression, they often don’t use a validated screening measure.

Recency of training and sex differences are present when comparing those who screen more frequently, with more recent residency and female physicians screening more.

Ververs et al. [25]

To investigate where GPs and pharmacists in the Netherlands obtain information on the safety of gestational drug use and the pharmacotherapeutic approach when managing depression and anxiety during pregnancy.

Quantitative: Closed choice multiple choice questions

Netherlands

130 GPs;

144 pharmacists

Contraindications regarding safety of medication make it difficult and depend on differing sources of information.

Differences in views on how to treat depression before, during and after pregnancy vary. GPs do consider the consequences of the mother’s illness outweighing the possible risks to the child. Concludes with the role of pharmacists being involved in developing clear policies and providing accessible information.

Williams et al. [26]

To explore the differences in the perception of teratogenicity risk of antidepressant and antianxiety medication commonly prescribed to pregnant women, medication counselling, prescribing practices, clinician resources and base knowledge of risk of antidepressant and antianxiety medications when used in pregnancy.

Qualitative: Survey

Australia

172 GPs;

373 Obstetrician/

Gynaecologists

GPs perceived higher rates of patient anxiety regarding anxiolytics and antidepressants, compared to obstetricians and gynaecologists. Both groups reported continued maternal concerns with fetal malformation due to medications. There is infrequent provision of written resources due to limited patient friendly resources. GPs often allotted more time in their consults to discussing medication risks and benefits.

GPs saw themselves in a primary prescriber role, comparatively, and were less likely to refer to a mental health specialist.

Both healthcare providers recommended a close patient-doctor relationship and clear communication when working with perinatal mental health and discussing medications.

There is a modest interest in mental health disorders in pregnancy leading to a general lack of familiarity in the area and limited knowledge of the latest evidence.