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\begin{document}

\title{Is collaborative care a key component for treating pregnant women with
psychiatric and psychosocial symptoms?: A systematic review.}



\author[1]{Celine Klatter}%
\author[1]{Leontien van Ravesteyn}%
\author[1]{Jelle Stekelenburg}%
\affil[1]{University of Groningen}%


\vspace{-1em}



  
  \date{May 20, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background: Mental disorders during pregnancy are common, with
long-lasting negative effects on mother and child. The combination with
psychosocial symptoms, barriers on population and healthcare level and
lack of long-term evidence make treatment challenging. To overcome this,
there is raising awareness for collaborative care. Objectives: Review
perinatal mental health interventions and analyse the impact of
collaborative care. Search strategy: Two independent reviewers searched
for RCT's in Pubmed, Embase and PsycINFO. Selection criteria: Trials
studying the effect of psychological or pharmacological interventions on
the mental health of pregnant women with psychiatric and/or psychosocial
symptoms. Data collection and analysis: Two reviewers independently
abstracted data and assessed study quality and risk of bias. Each study
was scored on collaborative care criteria: multi-professional approach
to patientcare, structured management plan, scheduled patient
follow-ups, enhanced interprofessional communication. Main results: 35
studies were included. Most trials studied the effect of cognitive
behavioural therapy and interpersonal psychotherapy on perinatal
depression. Almost all interventions met at least one collaborative care
criteria. Interventions were mostly provided by multiple professionals,
but interprofessional communication rarely took place. Interventions
that met more criteria did not more often show a positive effect on
maternal mental health. Conclusions: There is lack of research on
perinatal psychiatric disorders other than depressive and on long-term
treatment outcomes. Collaborative care is partly implemented in most
current interventions, but more trials (including interprofessional
communication) are needed to be conclusive whether collaborative care is
a key component in perinatal mental healthcare. Funding: None Keywords:
pregnancy, mental disorders, psychosocial, collaborative care%
\end{abstract}%



\sloppy


\textbf{Is collaborative care a key component for treating pregnant
women with psychiatric and psychosocial symptoms?: A systematic review.}

Celine K. Klatter\textsuperscript{1,2}, Leontien M. van
Ravesteyn\textsuperscript{1}, Jelle Stekelenburg\textsuperscript{1, 2}

1 Department of Global Health, Medical Sciences, University of Groningen
/ University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen,
The Netherlands

2 Department of Obstetrics and Gynaecology, Medical Centre Leeuwarden,
Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands

Corresponding author:

C.K. Klatter

University of Groningen

Department of Obstetrics and Gynaecology, Medical Centre Leeuwarden,
Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands

Tel.: +31623049622

Email: celine.klatter@mcl.nl

\textbf{Running title:} Treatment of perinatal psychiatric and
psychosocial symptoms

\textbf{Abstract}

\textbf{Background:} Mental disorders during pregnancy are common, with
long-lasting negative effects on mother and child. The combination with
psychosocial symptoms, barriers on population and healthcare level and
lack of long-term evidence make treatment challenging. To overcome this,
there is raising awareness for collaborative care.

\textbf{Objectives:} Review perinatal mental health interventions and
analyse the impact of collaborative care.

\textbf{Search strategy:} Two independent reviewers searched for RCT's
in Pubmed, Embase and PsycINFO.

\textbf{Selection criteria:} Trials studying the effect of psychological
or pharmacological interventions on the mental health of pregnant women
with psychiatric and/or psychosocial symptoms.

\textbf{Data collection and analysis:} Two reviewers independently
abstracted data and assessed study quality and risk of bias. Each study
was scored on collaborative care criteria: multi-professional approach
to patientcare, structured management plan, scheduled patient
follow-ups, enhanced interprofessional communication.

\textbf{Main results:} 35 studies were included. Most trials studied the
effect of cognitive behavioural therapy and interpersonal psychotherapy
on perinatal depression. Almost all interventions met at least one
collaborative care criteria. Interventions were mostly provided by
multiple professionals, but interprofessional communication rarely took
place. Interventions that met more criteria did not more often show a
positive effect on maternal mental health.

\textbf{Conclusions:} There is lack of research on perinatal psychiatric
disorders other than depressive and on long-term treatment outcomes.
Collaborative care is partly implemented in most current interventions,
but more trials (including interprofessional communication) are needed
to be conclusive whether collaborative care is a key component in
perinatal mental healthcare.

\textbf{Funding:} None

\textbf{Keywords:} pregnancy, mental disorders, psychosocial,
collaborative care

\textbf{Tweetable abstract:} There is an important lack of evidence of
the role of collaborative care in perinatal mental healthcare

\textbf{Main text}

\textbf{Introduction}

Globally, mental disorders during pregnancy are common, with prevalence
rates of depressive and anxiety disorders around
12\%\textsuperscript{1,2}. Women disadvantaged by psychosocial problems
are even more likely to develop mental disorders\textsuperscript{3,4},
with prevalence rates of depressive disorders between 25\% and
47\%\textsuperscript{5}. These mental disorders do not only affect
pregnant women, but also have negative effects on the (unborn) child.
Psychiatric symptoms are risk factors for postpartum depression,
caesarean section, low birthweight and behavioural problems in late
childhood\textsuperscript{6,7,8,9}. There is growing evidence showing
that mental disorders during pregnancy are common and have long-lasting
consequences.

Current treatment options are psychotherapy and
pharmacotherapy\textsuperscript{10}. Because perinatal use of
antidepressants may have adverse effects on child development,
clinicians and women prefer psychotherapy\textsuperscript{10}. Studies
show that cognitive behavioural therapy (CBT) and interpersonal
psychotherapy (IPT) can be effective in reducing perinatal psychiatric
symptoms\textsuperscript{11,12}. However, these therapies seem less
effective for women with psychosocial problems\textsuperscript{13}.
Also, there is limited evidence of the long-lasting effects. Concerning
the organisation of care, several barriers are identified on patient,
provider and healthcare level\textsuperscript{14}. Of all pregnant women
diagnosed with a mental disorder, less than 10\% receive adequate
treatment (antidepressants or psychotherapy for \textgreater{}6 weeks)
and less than 5\% achieve remission of psychiatric
symptoms\textsuperscript{15}. Women with psychosocial problems are even
less likely to engage in treatment\textsuperscript{16}. These components
make treating pregnant women with mental disorders challenging.

To overcome these challenges, there is raising awareness for integrating
mental health care into obstetric care. Collaborative care plays a
central role in this multidisciplinary approach consisting of
obstetricians, midwives, psychiatrists, psychologists and social
workers. Research has shown that collaborative care in primary care is
effective in improving psychiatric symptoms and adherence to
treatment\textsuperscript{17,18}. A framework of collaborative care,
derived from a systematic review of complex system interventions for
treating depression in primary care, is designed by
Gunn\textsuperscript{19} and used in different systematic reviews in
order to identify key components of collaborative care in mental health
care. We adapted the criteria to the obstetric care setting, in order to
score interventions on the following collaborative care criteria:

\begin{enumerate}
\tightlist
\item
  A multi-professional approach to patient care
\item
  A structured management plan
\item
  Scheduled patient follow-ups
\item
  Enhanced interprofessional communication
\end{enumerate}

Whether collaborative care interventions are (more) effective in
treating perinatal mental disorders is unknown. The aim of this study is
to review perinatal mental health interventions and describe the impact
of the collaborative care criteria on maternal mental health outcomes.

\textbf{Method}

\textbf{Search strategy and study selection}

We searched for randomised controlled trials, published in peer-reviewed
journals, in the databases Pubmed, Embase and PsychINFO. The following
search terms were used to identify eligible articles: (1) pregnancy, (2)
mental disorders, (3) psychosocial problems, (4) treatment and (5)
randomised controlled trials. We used subject headings and free text
terms to likely retrieve all relevant articles. The search was conducted
on 31 January 2020 and updated on 20 December 2021.

The results of the search strategy were exported to EndNote, after which
duplicates were removed. Two authors (CK, LvR) reviewed the results on
title and abstract. In case of disagreement or doubt a third reviewer
was consulted (JS). Based on the criteria described below, full text
articles were assessed on eligibility. When there were multiple articles
from the same trial, the article with the most complete or relevant
outcomes was included.

\textbf{Selection criteria}

We included randomised controlled trials from inception till December
2021 if they

(a) examined pregnant women diagnosed with a mental disorder according
to a standardized diagnostic interview based on the DSM or ICD criteria,
with clinical psychiatric symptoms according to validated mental health
questionnaires (e.g. EPDS \emph{\textgreater{}} 10) or with two or more
psychosocial symptoms (low-income, minority status, unsafe (home)
situation, living place in a deprived area, substance abuse); (b)
evaluated a psychological or pharmacological perinatal treatment,
provided face-to-face or over the telephone by professional health
workers, with the aim to treat or prevent mental disorders; (c) reported
any of the following maternal mental health outcomes: psychiatric
symptoms (validated questionnaires, e.g. EPDS, STAI), incidence rates,
recovery rates or risk reduction of psychiatric disorders. Secondary
outcomes are any birth, neonatal, infant or biomarker outcome. A core
outcome set does not exist in this field. We excluded non-English
studies, abstracts, case reports and studies including postpartum women.
Also, studies on solely transcranial stimulation, food supplements,
eHealth, physical treatment and interventions provided by informal
health workers were excluded.

\textbf{Data extraction and analysis}

The following details of each study were extracted and described in the
summary table (table S2): first author, country, setting, (number of)
participants, (duration of the) intervention, control condition,
maternal mental health outcome and retention and compliance rates. The
retention rate is calculated as the percentage of women who remained
till the latest follow-up and the compliance rate as the percentage of
women who attended all sessions of all women allocated to the
intervention group. Birth, neonatal and infant outcomes are described in
another table (table S3).

The collaborative care criteria (CCC) and the collaborative care score
(CCS) of each study are summarized in table 1. The CCC are defined as
follows\textsuperscript{19}:

\begin{enumerate}
\tightlist
\item
  \textbf{A multi-professional approach to patientcare:} Care provided
  by a midwife or gynaecologist and at least one other health care
  professional (e.g., psychiatrist, psychologist, social worker,
  psychiatric nurse)
\item
  \textbf{Structured management plan:} Evidence based management plan
  according to the NICE or Marc\selectlanguage{ngerman}é guideline or national guideline derived
  from these\textsuperscript{20,21}
\item
  \textbf{Scheduled patient follow-ups:} One or more telephone or
  in-person follow-up appointments are scheduled during or after
  treatment to provide specific interventions, facilitate treatment
  adherence, or monitor symptoms or adverse effects (e.g., calls between
  sessions, evaluation of treatment goals, follow-up or booster
  sessions). Monitoring symptoms for research purposes was insufficient
  to meet this criterion. Also, active outreach for women who missed
  sessions and providing telephone sessions for women who missed a
  session was insufficient
\item
  \textbf{Enhanced interprofessional communication:} Team meetings,
  case-conferences, individual consultation/supervision, shared medical
  records, patient-specific written or verbal feedback between
  caregivers. Communication to check whether all involved therapists
  work according to the same instructions was not scored
\end{enumerate}

We contacted authors for additional information on CCC, when certain
information was missing or unclear (n=13, 3 replies). The CCS is the
total number of criteria met by an intervention. In table 2 we described
the relation between the CCS and the effect of the intervention on
maternal mental health. The effect of the intervention was cited as
positive (+) when maternal mental health was significantly better in (a
part of) the intervention group compared to the control group
at\emph{\textgreater{}} 1 follow-up moment. The score was +/- when there
was not a significant difference between both groups and negative (-)
when the maternal mental health was significantly worse in the
intervention group compared to the control group.

\textbf{Quality assessment}

To assess the methodological quality of the included studies we used the
Cochrane risk-of-bias tool for randomized trials\textsuperscript{22}.
The quality of all studies was assessed on the following domains: random
sequence generation, allocation concealment, blinding of participants
and personnel, blinding of outcome assessment, incomplete outcome data,
selective reporting and other sources of bias. Each item was rated as
low, unclear or high risk of bias, based on the information reported
(table S4). Studies were classified as high quality (not fulfilling 0-1
criterion), moderate (not fulfilling 2-3 criteria), and low quality (not
fulfilling \textgreater{}3 criteria).

\textbf{Patient involvement}

Not applicable

\textbf{Results}

\textbf{Study characteristics}

2746 records were identified, of which 171 were assessed for eligibility
based on title and abstract; 47 articles met the inclusion criteria (see
figure 1 flow diagram and table S1 excluded studies). These articles
describe 35 different trials, published between 2000 and 2021.
Depression was the most common studied mental disorder (k = 23),
followed by a combination of depression and anxiety (k = 5), insomnia (k
= 3) and tocophobia (k = 3). One study (k = 1) focused on a variety of
psychiatric and personality disorders. Of all studies, 16 included women
with a combination of psychiatric symptoms and psychosocial risk factors
(e.g., low socio-economic status, deprived area). CBT (k = 15) and IPT
(k = 6) were the most studied interventions. Other interventions studied
more than once were psychoeducation (k = 4), mindfulness-based therapy
(k = 4) and multicomponent therapy (k = 2). There were no studies on
pharmacotherapy only. A considerable part of the interventions (k = 15)
was provided to groups of women. The number of sessions varied between 2
to 16 sessions, which were mostly provided once a week.

\textbf{Depression and anxiety}

\emph{Cognitive behavioural therapy (CBT)}

Most included RCT's (k=12) investigated the effect of CBT on antenatal
depression. Part of the studies (k=6) examined individual CBT (6-14
sessions) modified to pregnant women, focusing on the specific problems
these women were facing. Three pilot
studies\textsuperscript{23,24,25}found significantly lower levels of
depressive or anxiety symptoms in the CBT group compared to the care as
usual group. Of the 3 larger trials, one study\textsuperscript{26} found
an intervention effect for women with high depressive symptoms, one
study\textsuperscript{27}described no significant effect, and one
study\textsuperscript{28}showed a negative effect of CBT compared to
usual care. The other 6 studies examined CBT modified to women with
additional psychosocial symptoms (e.g. low-income, minority group). Four
studies\textsuperscript{29,30,31,32}, including two pilot
studies\textsuperscript{29,30}, reported (significantly) lower
depressive symptoms in the CBT group compared to the care as usual
group. However, one of these study\textsuperscript{32} found a treatment
effect for high-risk African American women only and one study was not
powered to test for statistical significance. The other 2
studies\textsuperscript{,33,34} did not find a significant difference
between both groups.

\emph{Interpersonal therapy (IPT)}

Overall, 4 studies\textsuperscript{35,36,37,38} concluded that IPT (4-16
sessions) was more effective than usual care or a parenting education
programme. The other 2 studies\textsuperscript{39,40} did not report a
significant effect of IPT. All interventions were provided to women with
both psychiatric and psychosocial symptoms. A recently published pilot
study compared IPT with CBT, which both showed a positive effect on
depressive symptoms.\textsuperscript{41}

\emph{Psychoeducation}

Both studies on psycho-education\textsuperscript{42,43} (6-8 sessions)
showed a significantly positive effect on depression rates or symptoms
compared to care as usual and the self-help book only group.

\emph{Mindfulness-based therapy}

Three articles\textsuperscript{44,45,46} described mindfulness-based
interventions (e.g. CBT, mindfulness-based childbirth and parenting
group), which all showed positive findings concerning depressive and/or
anxiety symptoms compared to usual care.

\emph{Multicomponent therapy}

Two RCT's\textsuperscript{47,48} examined the effect of a multicomponent
treatment provided by a multi-disciplinary team. An
intervention\textsuperscript{47} providing the choice of brief IPT
and/or pharmacotherapy revealed a significantly positive effect. A
combination of weekly CBT, psychoeducation, body-oriented and relaxation
therapy\textsuperscript{48} was not more effective than individual
counselling sessions.

\emph{Other psychological therapies}

Both problem-solving skills training\textsuperscript{49} (5 sessions)
and behavioural activation\textsuperscript{50} (10 sessions) were
reported as effective in reducing depressive (and anxiety) symptoms. A
group preventive risk-reducing treatment to prevent postpartum
depression\textsuperscript{51} and psychosomatic
programming\textsuperscript{52} did not reveal a significant effect of
the intervention compared to usual care.

\textbf{Insomnia}

Three studies\textsuperscript{53,54,55} showed that treating insomnia
might lead to reduction of depressive symptoms too. Both, 5 individual
sessions of CBT and 4 sessions of group behavioural sleep education,
significantly reduced depressive symptoms during pregnancy.

\textbf{Tocophobia}

Two sessions of telephone psychoeducation by a
midwife\textsuperscript{56} as well as cognitive therapy for
tocophobia\textsuperscript{57} significantly reduced the level of fear
of childbirth or birth-related concerns compared to written information
about childbirth. Also, mindfulness-based childbirth and parenting group
sessions\textsuperscript{58} led to significantly lower levels of fear
of childbirth compared to enhanced care as usual.

\textbf{Secondary outcomes}

\emph{Retention and compliance rates}

Retention rates differed between 31\% and 100\%. Compliance rates
differed between 23\% and 100\%. The lowest retention rate of
31\%\textsuperscript{42} and the lowest compliance rate of
23\%\textsuperscript{29} concerned studies focusing on women with
low-income or women stemming from a minority group.

\emph{Birth, neonatal and infant outcomes}

Positive effects of perinatal interventions on birth, neonatal and
infant outcomes are described (e.g., reduction of preterm birth rate,
lower caesarean rate, higher scores on self-regulation and
stress-reactivity at 9-months).\textsuperscript{25,28,40,43,52,58,59-64}

\textbf{Collaborative care score}

Table 1 shows an overview of the CCC of all studies. Of the 35 studies,
33 interventions met at least 1 criterion and most studies met 2
criteria. A multi-professional approach to patientcare was the most
scored and interprofessional communication was the least scored
criterion. Of the 35 studies, 6 studies met all CCC. The studies with
high CCS scores of 3 or 4 (n=13) were all evidence-based interventions
(CBT, IPT, multicomponent, psychoeducation) provided by multiple
professionals to depressive women. All interventions with a score of 4
were provided to women with additional psychosocial risk factors.
Whereas the CCS 3 studies provided follow-up sessions after treatment
only, the CCS 4 studies provided more often follow-up sessions during
treatment. Also, more professionals were involved in the CCS 4 studies
and interprofessional communication took place. Of the 29
multi-professional interventions, 25 interventions were provided by a
gynaecologist/midwife and a mental health therapist. The other 4
interventions were provided by a team of 3 to 6 different professionals.

\textbf{Impact collaborative care score}

Studies with a CCS of 2 showed in relation to the other scores the most
interventions (k=14) with a positive effect on maternal mental health
(see table 2). Interventions with higher scores did not show more often
a positive effect than interventions with lower scores. Of the 24
interventions with a positive effect, 20 studies met the criterion of a
multi-professional approach to patient care. The ranges of retention and
compliance rates are also described in table 2. These do not show a
clear pattern. However, all studies with the highest retention rates
of\emph{\textgreater{}} 90\% (k=7) and studies with the highest
compliance rates of \emph{\textgreater{}} 60\% (k=6) met the criterion
of a multi-professional approach to patientcare. The few studies that
scored on interprofessional communication had predominantly high
retention and compliance rates. Altogether, although a higher CCS did
not always show a positive effect or higher retention and compliance
rates, almost all interventions with a positive effect on maternal
mental health and with high retention and compliance rates met the
criterion of a multi-professional approach to patient care.

\textbf{Study quality}

Most studies had a medium risk of bias, due to insufficiently describing
one or more criteria, leading to an unclear risk of bias. Blinding of
participants and personnel to the given intervention was most times
impossible, which could have led to a high risk of performance bias.
Additionally, most outcomes were self-reported measures, which could
have attributed to the risk of bias when participants were not blinded
for the intervention.

\textbf{Discussion}

\textbf{Main findings}

The aim of this study was to give a systematic overview of all current
perinatal mental health interventions and to describe the role of
collaborative care. The current available interventions are almost all
either evidence-based or multidisciplinary, which means almost all
studies met at least one collaborative care criterion. Interventions
with a higher collaborative care score did not more often show a
positive effect on maternal mental health.

Almost all included trials (n=28) focused on treating women at risk of a
depressive disorder. CBT and IPT were the most studied interventions.
Both therapies were predominantly effective in reducing psychiatric
symptoms. The effects of other interventions are each based on a few
trials with small numbers of participants. Potentially beneficial
interventions are mindfulness-based therapy (3 trials), multicomponent
treatment (2 trials), psychoeducation (2 trials) and behavioural
activation (1 trial). The results of the few studies on tocophobia and
insomnia showed promising findings in reducing depressive symptoms and
symptoms of fear.

Although we could not find a clear effect of the CCS on maternal mental
health, we did find that a multi-professional approach to patientcare
could be essential in the treatment of pregnant women with psychiatric
and psychosocial symptoms. Almost all interventions with a positive
effect on maternal mental health and all studies with high retention
(\emph{\textgreater{}} 90\%) and compliance (\emph{\textgreater{}} 60\%)
rates met this criterion. Interventions provided by a multi-professional
team consisting of more than 2 different professionals (\textgreater{}
gynaecologist/midwife and a mental health therapist) were rare, as well
as interprofessional communication which was the least scored criterion.

\textbf{Strength and limitations}

This review extends the literature about the challenges in perinatal
mental health care\textsuperscript{13,65,66} by giving a new broad
overview of all current available therapies in this field and describing
the role of collaborative care in this treatment. We limited our study
to RCT's only, which means we could have missed other potentially
contributing studies. CBT and IPT were the most studied interventions,
but we found a high heterogeneity within these interventions (e.g.
content and number of sessions). Other interventions were studied by
just a few trials. Also, retention and compliance rates were difficult
to compare, because of the variation in the number of provided sessions
and the time of follow-up. Another limitation is the lack of received
additional information on CCC of the contacted authors, which could have
led to an underestimation of the CCS's. In short, this review gives a
broad overview of studies, although there is high degree of
heterogeneity on population, interventions and outcome measurements,
which makes interpretation of findings difficult and decreases
generalizability.

\textbf{Interpretation}

To our knowledge this is the first review about collaborative care in
the setting of perinatal mental health care, which makes it difficult to
compare these results with previous findings. Research in perinatal
mental health care did mainly focus on the effect of psychotherapy on
depressive symptoms. The predominantly positive findings of CBT and IPT
are in line with previous research that showed that CBT and IPT -
interventions advised by the NICE guideline - are effective in treating
perinatal depression\textsuperscript{11,12,13,20,21}. The treatment of
women with additional psychosocial symptoms, resembling clinical
practice, is less studied. A systematic review of
Nillni\textsuperscript{13}, et al. about the perinatal treatment of
depression and anxiety disorders also included women with psychosocial
problems (low-income and/or a minority status). However, this review
showed, unlike our review, mixed findings of both CBT and IPT in this
population. Especially the interventions with a high CCS focused on this
population. This could mean that a high CCS can have a positive effect
in populations with additional psychosocial symptoms.

As already noticed, collaborative care in primary care setting is
effective in improving psychiatric symptoms and adherence to
treatment.\textsuperscript{17,18,19} In obstetrics setting, Melville, et
al. conducted an RCT, in which a multidisciplinary care intervention
adapted to obstetrics and gynaecology clinics was compared with usual
care. The study reported a greater improvement in psychiatric symptoms,
better adherence to treatment and a greater satisfaction with care in
the intervention group.\textsuperscript{67} Although there is no
evidence about the role of collaborative care in the perinatal mental
health care setting, this review showed the developments in the field,
because almost all interventions were provided by multiple
professionals. However, interventions provided by multidisciplinary
teams of more than 2 different professionals (e.g., social worker) are
rare. Also, remarkable is that just a few studies met the criterion of
interprofessional communication. That means that obstetric care and
mental health care professionals were most times both involved, but that
communication, in a structured way, between them often did not take
place or was not reported. Further research should focus on the effect
of communication and collaboration between the different professionals,
which will enable personalized medicine, including shared decision
making between the patient and the different involved caregivers. Both
are important in (mental) health care and will eventually lead to
improved treatment adherence and more meaningful outcomes for the
patient.\textsuperscript{68} Because of the low number of trials that
met all collaborative care criteria, more trials are needed, to make a
clear conclusion about the impact of collaborative care on maternal
mental health and treatment adherence.

Last, this review shows which evidence is missing in the field of
perinatal mental health care . Almost all studies were about
interventions provided to women with depressive symptoms. Despite the
high incidence of anxiety symptoms during pregnancy\textsuperscript{2},
just 5 trials focused on women at risk of depression and anxiety. Only 3
trials were about women with tocophobia or insomnia. This shows there is
a clear need for more trials on psychiatric disorders other than
depression. Additionally, more research to interventions except from CBT
and IPT could lead to positive consequences in the field. For example,
promising results of mindfulness-based therapy were found in this
review. Although there is raising awareness for child outcomes, almost
all current outcomes are short-term mother or birth outcomes. Because of
the negative long-term effects of perinatal mental health disorders, for
future research it is recommended to examine long-term outcomes of
mother and child.

\textbf{Conclusion}

In conclusion, there is an important lack of evidence in the field of
perinatal mental health care. Available evidence now focusses on studies
evaluating CBT and IPT for treating perinatal depression. More research
is recommended on other psychiatric disorders, interventions and
long-term follow-up outcomes. Additionally, collaborative care and
especially a multi-professional approach to patient care is already
implemented in most available interventions. However, interprofessional
communication and multidisciplinary teams of more than two different
professionals are rare. More trials are needed (on the impact of
interprofessional communication) to be more conclusive whether
collaborative care is a key component in perinatal mental health care.

\textbf{Acknowledgements}

None

\textbf{Disclosure of interests}

None

\textbf{Contribution to authorship}

CK Klatter: data collection (screening abstracts and selecting eligible
trials), data extraction and analysis, methodological assessment,
manuscript writing

LM van Ravesteyn: data collection, data extraction, methodological
assessment, manuscript editing

J Stekelenburg: supervision data collection and analysis, manuscript
editing

\textbf{Details of ethical approval}

Not applicable

\textbf{Funding}

None

\textbf{References}

\begin{enumerate}
\tightlist
\item
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\end{enumerate}

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