This paper explores a Master of Social Work (MSW) student's experiences in engagement with structural social work during an advanced practicum with a perinatal mental health project in Northeastern Ontario. The goals of the advanced practicum were to: (a) improve reflexive practice, (b) improve understanding of structural social work, specific to social justice, and (c) improve understanding of the role of structural social workers within inter-organizational collaborations. Deconstruction of the engagement with each of the goals and the challenges in facilitation of the objectives are reviewed. Though there are issues and dilemmas facing those who wish to engage in structural social work, this advanced practicum experience was successful in improving the student's engagement with structural social work praxis.

Background Up to 34% of perinatal individuals experience childbirth as traumatic. These individuals are at increased risk for developing depression, anxiety, and posttraumatic stress disorder (PTSD) after the traumatic event. The objective of this study was to elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period after a traumatic delivery. Methods Individuals who delivered within the last three years and perceived their birth experience to be traumatic (n=32) completed an hour-long semi-structured phone interview. The interview included screening for PTSD, depression, and anxiety with validated instruments including the Posttraumatic Stress Disorder Checklist for DSM-V (PCL-5), the Patient Health Questionnaire depression scale (PHQ-8), and the Generalized Anxiety Disorder scale (GAD-7), respectively. Qualitative data was analyzed using a modified grounded theory characterizing participants’ barriers and recommendations for mental health support after traumatic births. Results Among participants, 34.4% screened positive for PTSD, 18.8% screened positive for major depressive disorder, and 34.4% screened positive for anxiety. Qualitative themes revealed multi-level barriers involving lack of communication, education, and resources which prevented obstetric professionals from recognizing and supporting patients’ mental health needs after a traumatic birth. Recommendations from participants included that 1) obstetric professionals should acknowledge trauma experienced by any individual after childbirth, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support is needed before the ambulatory postpartum visit. Conclusions There are multi-level barriers toward detecting and responding to individuals’ mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively follow-up and assess mental health care in the postpartum period.

Depression i samband med graviditet förekommer hos ungefär 10% av gravida och medför risker för den gravida och barnet. Många erhåller inte behandling. IKBT kan öka behandlingstillgängligheten och har visat sig effektivt jämfört med sedvanlig mödravård. Utvärderingens syfte var att undersöka skillnader i depressionssymtom före och efter fyra veckor i en IKBT-behandling mot antenatal depression och att jämföra skillnaderna med en tidigare RCT på en snarlik behandling. Huvudfrågeställningen var huruvida depressionssymtom minskar hos patienter med antenatal depression efter fyra veckor i en IKBT-behandling. 26 personer deltog i behandlingen. Förmätning jämfördes med senast kända mätningen efter fyra veckor. Dessa och de veckovisa mätningarna fram till vecka fyra, jämfördes med två icke-randomiserade kontrollgrupper. Skillnad mellan förmätning och senaste mätningen avseende grad av depressionssymtom var signifikant i genomfört t-test och symtomreduktionen tycks vara i nivå med resultat från den tidigare RCT-studien. IKBT skulle således kunna utgöra ett behandlingsalternativ för gravida med depression. Slutsatser bör dras med försiktighet. Framtida forskning inom fältet är av vikt för att validera resultat och för att ge underlag till utvecklingen av behandling vid antenatal depression. / Pregnancy related depression exists in approximately 10% of pregnant people and adds risks for the pregnant individual and the baby. Many are not treated. ICBT may increase the treatment availability and appears to be more effective than conventional maternal health care. The purpose of this evaluation was to examine differences in symptoms of depression before and after four weeks of ICBT-treatment for antenatal depression and to compare the differences with a prior RCT of a similar treatment. The main research question was whether symptom of depression decreases in patients with antenatal depression after four weeks when being treated with an ICBT-treatment. 26 persons participated in the treatment. Pre-measures was compared to the most recent measurement after four weeks. These, and the weekly done measurements up to week four, was compared with two non-randomized control groups. The difference between pre-measures and the most recent measurement regarding degree of depressive symptoms was significant in completed t-test and the reduction of symptoms appears to be on a par with results from the prior RCT. ICBT could be a treatment alternative for pregnant people with depression. Conclusions should be done with caution. Further studies in this field are of importance for validating results and to provide knowledge for the development of treatment for antenatal depression.

I Sverige drabbas ca 10 - 20% av kvinnor av depression under graviditeten eller efter förlossningen. Då tidigare forskning har gett indikationer på att depression kan ha en negativ inverkan på prenatal anknytning och mamma-barn bindning, är syftet med uppsatsen att undersöka detta hos mammor som genomgått internetbaserad kognitiv beteendeterapi (IKBT) för antenatal depression.  Denna uppsats skrevs i samarbete med den randomiserade DANA-studien om IKBT för gravida med depression. Uppsatsen var en prediktions- och sambandsstudie som tillämpar en inomgruppsdesign med tre mättillfällen; före och efter IKBT behandling samt postpartum.  Syftet med uppsatsen var bland annat att undersöka vilka faktorer som förutsäger mamma-barn bindning 8–10 veckor postpartum, samband mellan prenatal anknytning och behandlingsutfall samt samband mellan förändring i depression och förändring i prenatal anknytning under behandlingen. Resultatet indikerar att tidigare missfall samt prenatal anknytning före och efter behandlingen, kunde förutsäga mamma-barn bindning 8-10 veckor postpartum. Prenatal anknytning var inte en signifikant prediktor för förändring i depressionsnivå. Slutligen indikerar resultatet ett signifikant samband mellan förändring i prenatal anknytning samt förändring i depression före och efter behandlingen. / In Sweden, about 10-20% of women suffer from depression during pregnancy or after childbirth. As previous research has given indications that depression can have a negative impact on prenatal attachment and mother-infant bonding, the aim of the essay is to investigate this in mothers who underwent internet-based cognitive behavioral therapy (ICBT) for antenatal depression. This paper was written in collaboration with the DANA randomized trial of ICBT for pregnant women with depression. The design was a prediction and correlation study that applies a within-group design with three measurement occasions: before and after ICBT treatment and 8-10 weeks after childbirth. The purpose of the essay was, among other things, to investigate which factors predict mother-infant bonding 8–10 weeks postpartum, the relationship between prenatal attachment and treatment outcome, and the relationship between change in depression and change in prenatal attachment during treatment. The results indicate that previous miscarriages and prenatal attachment before and after treatment could predict mother-child bonding 8-10 weeks postpartum. Prenatal attachment was not a significant predictor of change in depression level. Finally, the results indicate a significant relationship between change in prenatal attachment and change in depression before and after treatment.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.

Background: Bipolar disorder (BD) is a significant cause of perinatal morbidity and mortality. Because BD is hard to detect and treat, these individuals often go without care. This dissertation was designed to: (1) identify the prevalence rates of BD and bipolar-spectrum mood episodes in perinatal individuals, (2) understand pertinent barriers to mental healthcare, and (3) elucidate how to bridge healthcare gaps. Methods: Data sources included: primary qualitative and quantitative data from obstetric clinicians, encounter data from Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, a program aimed at helping clinicians to provide mental healthcare to perinatal patients. Analyses included: descriptive statistics, systematic review and meta-analysis, qualitative data analyses, longitudinal regression analyses, and group-based trajectory modeling. Results: The prevalence of BD in perinatal individuals was 2.6% (95% CI: 1.2 to 4.5%). Twenty to 54.9% were found to have a bipolar-spectrum mood episode. Barriers to mental healthcare for perinatal patients with BD included the paucity of psychiatric resources, difficulties in assessing BD, and stigma towards pharmacotherapy. Obstetric clinicians reported that MCPAP for Moms has helped them feel more comfortable in treating patients with BD. Longitudinal analyses of encounter data corroborated these findings - utilization of the program predicted increased clinician capacity to treat BD. Conclusion: Clinicians for perinatal individuals are being called upon and stepping up to care for complex illnesses like BD. Programs like MCPAP for Moms can help them feel more confident in this role, helping to bridge gaps in perinatal mental healthcare and ensuring that individuals with BD are able to receive appropriate care.